Could this procedure be the mother of all post-pregnancy surgeries? Phoon Chi Ho interviews Singaporean plastic surgeon, Dr. Woffles Wu to find out more.
These days, being a mother comes with an additional responsibility. With barely enough rest from childbirth and months of pregnancy, many new mommies today are pressured by society and the media to be back in action with their pre-pregnancy bodies, if not better. In their quest to recapture their former figures, exercise, dieting, and slimming centres are some of the choices but surgery may be the best option to repair their loose bellies.
While many opt for other post-pregnancy surgeries like tummy tucks, liposuctions and breast lifts, Dr. Woffles Wu, a plastic surgeon from Singapore, sees the importance of repairing the rectus abdominis muscle.
“I have many patients who come up to me weeks after their childbirth and complain that their friends and family still think they are pregnant!” says Dr. Wu.
And there is a reason why.
But before any reasons are given, it is best to understand the anatomy of the muscle mentioned, especially those of a pregnant woman. Generally known as the abs, the rectus abdominis muscle is a paired muscle that runs vertically, from the lower chest to the pubic bone, on both sides of the human abdomen’s anterior wall and separated by a midline connective tissue called the linea alba. The main function of the muscle is to bend the spine and keep abdominal internal organs intact.
During pregnancy, the structure of the rectus abdominis muscle changes. “At the later stages of pregnancy, due to the expanding ribs and baby, the muscle splits in the middle of the abdomen, pushing it aside and creating gaps on the muscle walls,” explains Dr. Wu. The splitting of the muscle, or diastisis rectus, is a normal process during pregnancy; some women may even experience this as early as the 5th month of pregnancy. Other than making space to accommodate the growing baby, it also allows the baby to move forward rather than being pushed back towards the mother’s spine. There is almost no pain involved in the process as there is no rupture or tearing of the muscle. Rather, the muscles separate and thin out to create more space in the abdomen. Although diastisis rectus is generally associated with pregnant women, certain men with severe obesity might experience it as well.
However, it is quite unlikely that the muscle will tighten on its own following childbirth. “After pregnancy, although the muscle shrinks back to its normal size, it may continue to remain separated and this leads to the loss of the flat shape of the tummy,” states Dr. Wu. “Basically, the rectus muscle has lost its mechanical advantage by being seperated in the midline.This is clearly visible while lying down on your back and trying to do a sit up. A normal tummy is supposed to be flat throughout the action. However, for a woman after childbirth, the tummy becomes rounded and protrudes in the middle. In the standing position, that bulge is still visible. This is because when the muscles are separated and pulled aside, the stomach bulges forward.” Without medical attention to reattach the separated muscles, the mother may be prone to complications such as chronic lower back pain and altered posture due to a weak abdominal muscle, not to mention a protruding belly.
To restore mechanical function of the muscle and get that desirable flat belly, a surgery termed the ‘rectus muscle repair’ can be performed. “This is done by repairing, realigning and tightening the middle of the rectus muscle (linea alba) from the pubic area to the xiphisternum (the lower end of the sternum that is not attached to any ribs),”explains Dr. Wu. “The surgery helps restore integrity of the muscle to its pre-pregnancy form”. Performed under deep sleep or general anaesthesia, the surgery can last between two to three hours.
Patients need to be observed and an overnight stay for at least one to two days is required. On the second day after surgery, patients should be able to walk and perform sedate activities with slight discomfort. After 12 to 13 days, the stitches will be removed and subsequently, patients can return to work although it is advisable to give heavy tasks a pass. By six to eight weeks, patients should be able to return to normal routines.
(WILL THERE BE ANY SCARRING LEFT BY A RECTUS REPAIR PROCEDURE?)
In some instances, patients can choose to top-up on the procedure. “Rectus muscle repair can also be coupled with a tummy tuck and liposuction,” says Dr. Wu, “The objective is to achieve a flat tummy.” Various techniques of tummy tucks may be used, namely minituck, endoscopic tummy tuck (keyhole surgery) or complete tummy tuck, depending on the severity of the bulge, excess abdominal skin and stretch marks. Liposuction can also be done along with or on its own to remove excess fat deposits in particular areas for body contouring.
(IS RECTUS REPAIR MORE COMMONLY DONE WITH A TUMMY TUCK, THOUGH?)
The rectus repair is invariably done at the same time as a tummy tuck procedure which takes care of the excess skin and fat. It is possible to repair the rectus on its own but this is seldom done. My personal preference is to start off with a liposuction of the abdomen, flanks, hips and back and then proceed with a tummy tuck and rectus repair. In the past I used to do Tummy tucks without lipo but the results were not as good. And I would almost never perform a tummy tuck without the rectus repair.
(IF RECTUS REPAIR IS COMBINED WITH ABDOMINOPLASTY AND LIPOSUCTION, HOW LONG WILL THE PROCEDURE BE?)
The procedure is about 5 hours.
(WHAT IS THE AFTERCARE LIKE FOR THE COMBINED SURGERIES?)
Patients are walking about one to two days after surgery and should be able to get back to office within a week.
(WHAT ARE THE POTENTIAL COMPLICATIONS)
Post-surgery complications of the mentioned procedures may include infections, bleeding, wound breakouts, keloid scars (raised scars) and seroma (a small collection of fluid under the skin) although the percentages of such complications are very low. For abdominoplasty, there is no escaping the fact that the patients will bear a prominent scar below the stomach area but this can be easily concealed by clothing. According to Dr. Wu, this scar is unavoidable as the procedure involves excess skin being ‘cut’ out. Wound infection, seroma, wound dehiscence or splitting can occur as potential complications. Liposuction, on the other hand, may pose the risk of irregular contouring, deep vein thrombosis, infections or even abdoiminal perforation on very rare occasions. Always seek a surgeon’s advice to recommend appropriate procedures, to iron out risks and to minimize complications.
(WHAT IS THE COST OF A RECTUS REPAIR ALONE?)
I never do a rectus repair on its own.
After all that is said, it is recommended that one only considers any of the mentioned mommy makeover procedures at least six months after childbirth to allow hormones to equalize and the body to recuperate from physical changes experienced during pregnancy and childbirth. As the tummy’s degree of expansion also plays a part, this recuperation period varies from mommy to mommy based on the size of their baby and the number of babies they have had. For post-pregnancy mommies choosing to undergo a tummy tuck or liposuction, there is the need to stabilize their body weight and physiological condition first so surgeons can determine the proper amount of skin or fat to be removed.
It is also advisable to consider these surgeries after the completion of their family. However, those who opt for rectus muscle repair and abdominoplasty procedures despite this, can continue to have babies after the surgeries as the same procedures can be repeated over. The plus point for these patients is, while the tummy may become loose again, its integrity is stronger than those without previous procedures performed.
Rectus muscle repair should always be considered in any tummy tuck. Dr Wu says, “Rectus muscle repair after pregnancy is more common than most people think. It’s always better to take the opportunity of repairing the muscle whenever a tummy tuck is being performed.”
GAP OR NO GAP?
To find out whether you have diastisis rectus, a simple “Rectus Test” can be performed on your own or under supervision by a doctor. First, lay on your back with your feet flat on the ground and your knees bent. Then, put your finger tips on your tummy just above your navel and face them towards your feet. Slowly, lift your head and shoulders off the ground. If your rectus abdominis is separated, you will be able to feel a gap that is at least two fingers wide. If it is joined, there should not be any gap.
ABDOMINOPLASTY
More commonly known as a tummy tuck, abdominoplasty is a popular cosmetic procedure to firm the tummy. It involves the removal of excess skin and fat from the abdomen to tighten the muscles of the abdominal wall. Ideal candidates are those with overhanging skin or laxness of muscles at the stomach area, usually caused by pregnancy or massive weight loss. To compliment a rectus muscle repair, a complete tummy tuck is recommended.
Done under general anaesthesia, the procedure begins with a bikini-like incision (a cut across the hip just above the pubic area). The belly button is then removed from its surrounding tissue for repositioning later. Next, the skin is separated from the abdomen and lifted up to the ribs to expose the abdominal muscles, which are then tightened to its original position. When that is completed, the skin flap is pulled back down before excess skin and fat are removed. The navel will also be repositioned and sutured in place. The surgery ends with the closure of the incisions, application of dressings and the placement of pipes to drain excess fluid for the next one or two days.
LIPOSUCTION
Short for suction-assisted lipectomy, liposuction is a marginally invasive cosmetic surgery to permanently remove excess fat cells from specific areas like the breasts, abdomen, thighs, buttocks, and especially where exercise and dieting have failed. Patients with a good physique, good skin tone, not exceedingly overweight and preferably, below forty years of age (due to better skin elasticity, although older patients can also yield good results) are the best candidates for the procedure.
Liposuction can be performed under local or general anaesthesia on an outpatient basis. During the procedure, small incisions (about one centimetre) are made on inconspicuous areas of the body near the location where fat will be removed. A cannula-like device (a hollow tube) is then inserted through the incisions before suctions begin. The amount of fat removed is determined by the doctor, patient and method used while surgical duration is determined by the extent of the procedure. For one area, the recovery period can last up to three days whereas for multiple areas, it can last up to two weeks.
