Episode 21: Sunday November 8

Drs. Sam Jejurikar, Salvatore Pacella, and Sam Rhee discuss a case in restoring the shape and appearance of after childbearing. Many women notice changes in their bodies post-pregnancy. There are many areas of the body that can be addressed and there are many techniques used to perform a mommy makeover.

The 3 plastic surgeons talk about the many factors should be taken into consideration when choosing which techniques are best. If you are interested in the latest and greatest in Mommy Makeovers, this episode is a MUST WATCH!

Full Transcript (also download PDF here)
Dr. Salvatore Pacella: [00:00:00] Good morning, sunshine. How's everybody today. 
Dr. Sam Jejurikar: [00:00:03] Wonderful. 
Dr. Salvatore Pacella: [00:00:05] Fantastic. as once again, we're joining us, everybody's joining us for Three Plastic Surgeons and a Microphone. It's where it's at. I'm aware it's at right now in San Diego. I'm Dr. Sal Pacella from LA Jolla, California. My Instagram handles @SanDiegoplasticsurgeon.
I'm joined of course by my good friends and colleagues. Dr. Sam Jejurikar from Dallas, Texas, whose Instagram handle is @SamJejurikar. And of course, Dr. Sam Rhee from Paramus New Jersey. Who's @Bergencosmetic. How are you gents today? Doing well? 
Dr. Sam Rhee: [00:00:37] Doing awesome. 
Dr. Sam Jejurikar: [00:00:39] Doing so well. 
Dr. Salvatore Pacella: [00:00:40] All right. Great. we, we are on a schedule today.
We just had a changeover spring forward, fall back. so we're going to be airing the show next week, but, everybody's doing well, bright eyed and bushy tail. Then that's going to come to an end this afternoon at about four o'clock when we're all ready to go to sleep. Huh? 
Dr. Sam Jejurikar: [00:00:58] I feel like we're a little bit in a time machine too, because when this air is next week, the presidential election will be over outwardly.
There's going to be some form of chaos that has ensued in our nation. And right now we're naive to what it actually is. So here we are blissfully unaware of the events that are going to happen over the next week. 
Dr. Salvatore Pacella: [00:01:18] Marty McFly, going back to the future, it's going to be a 21 gigawatts. 
Dr. Sam Jejurikar: [00:01:23] I'm going to try it.
I'm not going to try to be fending off advances from my mother to have intercourse with me. I always thought that was, I always thought that was the strangest movie of all time. What, if you think about it, who comes up with this plot and I'm stealing this by the way from John Malaney V if you've ever seen his standup bit where he talks about how strange of a bit back to the future is where he's actually staying.
We're basically like who comes up with his idea. We're going to take this high school kid. We're going to put them in a time machine. We're going to make his best friend a nuclear physicist of unknown age. Never explained that relationship of any kind. Then we're going to send it back in time so we can date his mother, try to fend off sexual advances from his mother and basically stop her attempted rape.
Yeah. That's going to make a great movie 
Dr. Sam Rhee: [00:02:15] when you put it that way. Oh my God. 
Dr. Sam Jejurikar: [00:02:17] I highly encourage you to watch the John Malaney, but it is astounding. 
Dr. Salvatore Pacella: [00:02:21] it's almost, it's almost the same, concept as the terminated, right? go back in time. The original Terminator was like that too.
that's a good segue into our next topic, which is money makeover. That's fantastic. Dodger Jejurikar are I'm going to hand it over to you in a second for the case, but, let's just do our, disclaimer here. This show is not a substitute for professional medical advice, diagnosis or treatment.
This show is for informational purposes, only treatment. The results may vary based upon the circumstances, situation and medical judgment after appropriate discussion. Always  seek the advice of your surgeon or other qualified health provider. With any questions you may have regarding medical care, never disregard professional medical advice, or delay seeking advice because of something in the show.
so let's get going here. We're going to talk about mommy makeover. That's fantastic topic. Wonderful 
Dr. Sam Jejurikar: [00:03:12] future 
Dr. Sam Rhee: [00:03:15] Marty McFly would approve of this topic today 
Dr. Sam Jejurikar: [00:03:19] and that's all we can hope for. yes, as we have a, alluded to today's topic is mommy makeover and it's a conglomeration of multiple previous episodes that we've done before.
I'm going to imagine that dr. Patella in San Diego, dr. Ray in New Jersey. We get calls from prospective patients every day, where they want to know what the cost is for mommy makeover, what the recovery is for a mommy makeover. but as we'll see much everyone's experience with having kids is different.
so as the changes that actually happened to the body, with pregnancy and If you think about how every woman that's out there with pregnancy, some of them gained 20 pounds. Some of them gain a hundred pounds. Some of them breastfeed, some of them don't breastfeed. Some of them have preexisting droopiness to their breast.
Some of them are perfect. Physical women are different. And thus the changes that happen to the female body changes, So much from patient to patient. And what is a mommy make over? It's a lot of different things and it's not a cookie cutter, formulation to all patients. So if you think about it, some women, they lose volume when they breastfeed.
other women get droopy, some women lose volume and get droopy. So we could see the breast augmentation or a breast lift, or a combination thereof as needed. In many patients. Some patients actually gain breast tissue with, with pregnancy. And so they need to have a lift. They need to have a reduction.
I think the one operation that's relatively constant across virtually all a mommy makeover is the need for a tummy tuck. We've done a previous episode on Tommy talk, but just to refresh our viewers. Okay. with, changes in pregnancy, you changes, changes to the abdominal wall muscles, changes, to the scan where you have loss of skin elasticity.
You can get extra fat of the abdominal wall and the flanks. in addition, you can get fat of the back, the thighs, the arms, the neck, there's a lot of different places where people get fat. And want to get liposuction as part of a mommy makeover. in my practice, I'll see a lot of patients actually complain that they get deflation of the buttocks and buttock augmentation can be part of it.
It's a little complicated. I've have found to do, a fat transfer to the buttock and the Tommy talk from a positioning standpoint, but there are usually. Ways around that. And then, more and more seeing patients and I don't do these procedures labioplasty and vaginoplasty, but a lot of times we'll get a cosmetic gynecologist involved where you'll actually see changes to the, to the, female genitalia.
If you think about it, you get expansion of the abdominal wall and the pelvic floor, and so changes to both the vagina and the labia are very common. So we have found that in this, 
Dr. Salvatore Pacella: [00:05:51] dr. J I ask you a quick question here? okay. in general, would it be correct to say that, when patients are asking for a mommy makeover, that's usually a combination of a breast procedure and some other type of body procedure, correct.
Dr. Sam Jejurikar: [00:06:06] That's my interpretation of it. I'm curious if you agree with that as well. Yeah. 
Dr. Sam Rhee: [00:06:12] Yeah, I think those are the areas that are changed most by pregnancy and going through pregnancy. 
Dr. Salvatore Pacella: [00:06:18] Yeah. And w one common question I always get from moms in San Diego is, I'm considering getting pregnant and would it be a good idea for me to do liposuction now before I get pregnant?
So my skin is tight and maybe I won't need a tummy tuck afterwards. How would you answer that? What would you tell them? 
Dr. Sam Jejurikar: [00:06:38] I would tell them. and I won't speak for dr. But my general thought process is that the changes that happened during, during pregnancy are, severe and unpredictable across the board.
But the majority of women who have two or more children that I see almost always need a tummy tuck to get to their prepregnancy. abdominal wall, I'd probably guess that probably 75% that have one or one child or more probably need to have a tummy tuck. So I wouldn't find that doing liposuction in and of itself, is going to have any protective effect whatsoever.
What do you guys think about that? 
Dr. Sam Rhee: [00:07:10] I get even, I think a related question I get more of is maybe someone who's had one child and is thinking about getting body contouring or some other breast lift type procedure. And I, if they're still in the family planning stage, I will tell them, this is something you have to take into consideration that if you have a kid in the next year or two results may change, and that's something that, families and patients have to take into consideration.
Dr. Salvatore Pacella: [00:07:36] I would agree. And I think there's a no cosmetic surgery or plastic surgery that you can perform in the abdomen. That's going to prevent the changes of pregnancy, I think. And in fact, I sometimes see patients who have had tummy tucks years ago that incidentally decide. Or, get pregnant for some reason.
and maybe it's a surprise. Maybe it's a plan, et cetera. And the act of tightening the abdominal muscles won't prevent the uterus and the baby from expanding. do you agree or. 
Dr. Sam Jejurikar: [00:08:09] I 100% agree with that. I have had probably at least 20 patients who have done tummy tucks on that have subsequently gotten pregnant and across the board, when they come back for the revision tummy tuck, they relay a story where the first four or five months they don't look like they're particularly pregnant and then very suddenly, and usually there's some pain associated with it as well.
They look. Very pregnant and that's disruption of the repair that we've done in the muscle. and yeah, I don't think, I think that the baby develops just fine, but I think they're there that the baby is a stronger, unyielding force on the abdominal wall that always wins. 
Dr. Salvatore Pacella: [00:08:50] and, the other thing I think is really important is, the.
The destruction of the abdominal wall that we see, as you mentioned in alluded to it's very unpredictable. I can see, I see tiny fit women that, do yoga. Do planks are incredible shape that after pregnancy, their abdomen is just completely destroyed. I see other gals who are in equal amount of shape that look just totally fine afterwards.
It's just very unpredictable. what children could do for us. They, they ruin our bodies and sacrifice our dreams, right?
Dr. Sam Jejurikar: [00:09:27] They're the best thing and the worst thing that can happen. So I completely agree. That's really anything you want to add to that before I move on to the case? 
Dr. Sam Rhee: [00:09:38] No, that's a very sad thought to continue with keep going 
Dr. Sam Jejurikar: [00:09:44] as a father of three children. I wish I could say that I disagreed with dr. Pacella, but I cannot. I actually have up to two cases we can show or we'll just show one kind of, depending on time here. But, this case is a patient that I met over the pandemic operated on over the pandemic and is a few months out. Which is a sign of how long the pandemic has been going on.
but she's a woman in her late thirties. Who's a mother of four children, stated with, with certainty that she was done having children, as you'll see from the pictures, she has, she meets some of the classical criteria for potentially needing a breast lift, but really didn't want a breast lift was okay.
Accepting additional volume if I thought that wasn't and that was an alternative, and I'm going to be curious to get your guys' thoughts on this as we, as we progress. And then she really wanted her, not only her timing to be flat, but she wanted to have a curvier shape to her body. so here are her preoperative pictures.
And, when one of you guys like to chime in with what you think is going on here and what your approach to this would be sure. 
Dr. Salvatore Pacella: [00:10:42] Dr. Rhee, why don't you go ahead. Okay. 
Dr. Sam Rhee: [00:10:44] she certainly does look like the mother of four looking at her abdomen. She's she has, a very, a protuberant abdomen.
You can see the skin excess, you can see, stretch marks, and that loss of, abdominal wall integrity. I know what you're talking about in terms of the breast sagging and ptosis. I think I would give her a long talk, about what her goals were in terms of her breast appearance.
If I agree with you, if she really wanted to go larger with her volume size, I might consider trying just an odd, an augmentation with implant only, with the caveat that maybe she might need a lift in the future. otherwise, if she didn't really want to change her breast volume, much at all, then she really would need a breast lift.
she, otherwise is relatively thin in proportion and doesn't, she's not particularly obese in any way. And it's really that midsection that you see, indicative of pregnancy changes. That probably is one of the biggest changes for her from pre pregnancy to post-pregnancy. 
Dr. Salvatore Pacella: [00:11:48] Yeah, I agree. and I'm going to first start at the top here.
So looking at her breasts, I think, your photographs here have, this patient with her arms elevated now. And I think that artificially can raise the breast position up. So I'm just imagining what her. What her arms would, what it would look like if her arms were down. And I imagined that the nipple and breast position would be down a little bit.
So I think the important thing for my discussion with her was talking about size and that determines whether or not I'm going to do just a simple mastopexy or breast lift versus a lift with an implant in my mind, not. Really being able to see where the nipple position is. It looks to me like she's got a look, a little bit of two ptosis and pseudoptosis, and in my experience with just an ARG.
Oftentimes a year or two, five years later, we can get that little bit of waterfall deformity to the breasts, which is very, unaesthetic the implant sometimes rides up a little bit high and the whole breast tissue sorta falls off. So I'd like to, I'd like to stop that from happening. So I think I definitely offer a lift, in looking at her abdomen.
I think she's just a perfect candidate for an abdominoplasty traditional, Rectus plication or tightening of the muscle? abdominal plasty. It also looks to me, does she have a little bit of an umbilical hernia here? 
Dr. Sam Jejurikar: [00:13:07] Tiny one, for sure. Yeah. 
Dr. Salvatore Pacella: [00:13:08] Yeah. And so gents, in, New Jersey and Dallas, what's your standard with, the umbilical hernia that you find preoperatively and when you find incidentally, do you work with a general surgeon?
What's your, do you repair that yourself? What are your thoughts on that? 
Dr. Sam Rhee: [00:13:23] and in New Jersey, and most of the hospitals, we are not, if you're not double boarded in both general surgery and plastic surgery, you cannot do umbilical hernia repair on your own. However, if it's in conjunction with a body contouring procedures, such as an abdominal plasty or a panniculectomy, then we can do the umbilical repair.
And so I usually do not. involve a, a general surgeon, unless there's some complication or something very large. And, I'll generally handle it myself. 
Dr. Sam Jejurikar: [00:13:56] Yeah. I, similar, philosophically to what dr. Rhee saying, I think if it's a revision hernia, or if it's a particularly large hernia, I am very quick to get a hernia expert, a general surgeon who specializes hernia, repair, involved, most of and a previous episode, when we talked about Tommy tuck, dr.
Chella, you use an analogy that you described with your patients where you described that not only are the muscle separating, but everything is just stretching from the abdominal wall. So that. A lot of times what you'll see. And I know you guys will agree with us. You see the tiny fascial attachments between the rectus muscles.
Just get a little tear in it. And the repair of it is very straightforward to do. and then when you do the muscle tightening, which is going to be obviously very important for this, how many talk to make sure that her pregnant body habitus, goes away. you have a double repair of your hernia at the same time.
And so I feel really comfortable for one like this, just taking care of it while we're there. 
Dr. Salvatore Pacella: [00:14:52] Yeah, I do the same. I, my sort of rule of thumb is if I encounter one incidentally during a tummy tuck, I'll just go ahead and fix it. But if it's a big issue or say, even the general surgeon had sent the patient to me, With an umbilical hernia.
She's interested in doing an abdominoplasty at the same time. I'll usually, work as a team with the general surgeons. Honestly, it, I have a handful of general surgeons. I have an excellent relationship with we're at the same facility. it's pretty easy for them to just pop in for 10 minutes and throw a couple sutures in and every everybody's working.
Everybody's great. 
Dr. Sam Jejurikar: [00:15:25] yeah. I want to go back and follow up on something that you guys were talking about. dr. Pacella, you use terms like ptosis pseudoptosis, waterfall, deformity, which are all, very specific plastic surgery terms that we all toss around amongst each other. But, how would you explain to the patient who really doesn't want to have scars associated with the breast lifts, how you would size her implants, the thought processes that are going on in your head that would allow you to get an aesthetic result, because you're very accurate in your assessment of these pictures.
Unfortunately, I did not put the dedicated breast. Views on your, but she's got great two ptosis with our arms down, which to our, viewers means that the nipple position is somewhere between the ideal position in the center of the breast and the very bottom of the breast. And so in my mind, when someone is great to toast, it is, You can sometimes get away with not doing a breast lift, if you use an appropriately sized implant and sometimes you can't, how would you explain what our choices are 
Dr. Salvatore Pacella: [00:16:26] when you say appropriate size implant?
You mean everything else in Texas and Dallas big
that right.
Dr. Sam Jejurikar: [00:16:35] All joking aside. The way I explain it to patients is look, if you think about what happened during pregnancy, your breasts enlarge the skin, stretching along with it, then the breast tissue involuted, but the skin remains. So your choices are to fill up the skin that you have, or to pick an implant size sizes a little bit smaller and tighten the skin around it.
I don't think that's a unique Texas phenomenon, but, I'm going to regret when I show you the post-op as well.
Dr. Salvatore Pacella: [00:16:58] I explained the same process, which is, so you mentioned, we were, you already described what ptosis is. Pseudoptosis is very similar, however, it's a phenomenon where the nipple is an appropriate position, but the breast looks very droopy because the distance from the nipple to the fold has increased over time.
And that's caused by the same phenomenon, a reduction in breast volume, but having the skin not retract back. So I agree. many times you can get by with just a simple, large size implant to correct that. But many times, at least in San Diego, most patients are looking for a little bit more of an athletic, a little bit more natural  appearance, and it would be rare for me to be able to achieve that without using some sort of lift.
Dr. Sam Jejurikar: [00:17:48] Yeah. dr. Rhee, I have another question for you. One of the things that this patient was, really hoping to achieve with this operation was to look curvier with her surgery. how would you address that? Would you address that, specifically, are there things that you might add to the tummy talking the breast surgery to try to help her achieve that?

Dr. Sam Rhee: [00:18:05] a lot of patients do one. Curves like an hourglass figure or a, sometimes they lose that with pregnancy, as you alluded to before. certainly some backlight suction, might help her achieve more of an hourglass figure her, on the lateral, her glute contour looks projected, but her hips are not maybe so full.
And in my experience, a lot of patients who look like your patient will want her. hip dips filled. 
And so I think it would be reasonable to do, fat transfer to the hips to increase her contour in that area. If that's what she was looking for. 
Dr. Sam Jejurikar: [00:18:43] Great. let's, let's go, move on to her postoperative results and I'll talk to you.
What I did. It turns out I did a tummy tuck with, extensive muscle tightening, just dr. Rhee alluded to. I didn't do what everyone now on Instagram calls, LIBO three 60, but it's basically circumferential liposuction of the trunk, the back, the flanks, the abdomen. I did fat grafting to the hips to give her that's a curvier body shape, just like dr. Rhee was saying. And then I gave her Texas size implants. As dr. Pacella in San Diego was alluding to of use 545 CC high-profile implants. And, Here's how we look at it. These are about, I don't know, two months post-op I just saw her last month in the office. And so the most recent thought as we had on her.

Dr. Salvatore Pacella: [00:19:28] are those shaped implants or just a co high cohesive round? 
Dr. Sam Jejurikar: [00:19:34] Hi, cohesive round. I think, when you look at the variety of views, I think from the front, you definitely see that curvier frame with the hip and the fat grafting to the hip tips. I think, from the side view, you can see the effect of muscle tightening.
if you asked me what's the most important part of this entire case, it's going to be tightening over rectus abdominis muscles to give her a flat or contour. She still has some swelling. Cause she's again, she's still relatively early in the post-op process. She's about two months out. this is what a mommy make over can do.
I'm curious what, other than your scathing critique on the size of implants, I chose what you guys think about this. 
No, I say, I think this looks phenomenal. I joke and I say that in jest, I think, I think the thing to understand is when you have to understand proportion, right?
This gal is mid very mid-sized proportion. She's not rail thin. She's not obese by any means. And the size you chose is very natural with the caveat of filling in a deflated breast. So I don't see any evidence that she's disproportionate at all. Particularly with. In light of the fact that you added that fat transfer to the hips.
So she looks very hourglass shape. That thick is a great result. she's got a little bit of rippling in her abdomen, but that's really from the, just being early postoperatively, once that sort of thins out a little bit and gets in, get settled that it will go away. the scar will fade substantially over time.
it looks great limit. Let me ask you a question there. Doctor did your car. in Dallas, when you're planning on, designing the incision, the position of the incision. tell me how you do that. 
Okay. Great question. And, I make a concerted efforts to keep the incision as low as possible for about 90% of my patients will actually have a conversation about what are your goals with the incision, because as you guys know.
The incision is a deterrent for many patients that even have a tummy tuck. And so in this particular patient, it was important for her to, for it to be hidden in a bathing suit bottom. And when I design it, I have a few specific maneuvers that I'll actually use where they're stretching the skin upwards as I'm actually designing the incision to simulate the post-operative.
Pull. And with that, I actually measure the top of the vaginal introitus and I keep, keep the incision three to four centimeters above that. So really low centrally. And then we'll, we'll take it, lateral right at the junction of the, the thighs and the lower abdomen to, so it fits right in the bikini.
Do you 
Dr. Salvatore Pacella: [00:22:01] have them bring in a bikini? 
Dr. Sam Jejurikar: [00:22:03] I encourage them all the time. Most of them forget because there's so much stuff happening on the day of surgery where, they're just free dad, so we'll simulate it or we'll have ask questions about it and I'll draw in where I think it's going to be preoperatively and then design it to fall there.

Dr. Salvatore Pacella: [00:22:17] th this is an interesting phenomenon from our listeners here. and I'm sure you guys remember this throughout your career. early on in practice, when I started working with some older surgeons who may be, have been 20 years, my senior, many of those scars come up very high.
And that's a Testament to what the bathing suit design was in the, the early eighties and seventies, it was a very high. Wasted hip. and now what we see, around the nineties, two thousands is the position of the bathing suit. The position of the bottom bikini has dropped down a bit.
It's almost, they call it like the boy pants or boy style. and that has dropped substantially. and so even in the, in my 12 years of practice, the. That's bathing suit styles have changed. And so very rarely we get patients who, their scar started out 10 years ago in the right place.
And now. Just based on the bathing suit style has drifted and you can see a little bit of the edge of that. So that's an important discussion for us, for patients. 
Dr. Sam Jejurikar: [00:23:21] Yeah. 
Dr. Sam Rhee: [00:23:22] I really think that's a great result. I love, obviously you saw the preop and you saw just the huge rectus diastasis, just that large abdominal, laxity.
and you knew that you were going to get a great result with that just because that was significant preoperatively, but the other stuff that you do really, so anyone can really get that part of it down most, most surgeons that I know, but actually doing that three 60 lipo. 
Dr. Salvatore Pacella: [00:23:49] What is that a lot of surgeons
Dr. Sam Jejurikar: [00:23:52] I apologize. I apologize to the viewers. We have our own insights. 
Dr. Sam Rhee: [00:23:56] a good plastic surgeon. Or a competent plastic surgeon should that's the number one priority obviously is to address that big deformity. But what I also see that is very important that I'm an experienced plastic surgeon. not everyone, not Henry or Steve could do that three 60 lipo where you're getting that back to get more curve in that love handle lower lumbar area.
And then. I really love the hip tip. I do a lot of that hip tip, BBL, work. I wanted to ask you how much. volume. Do you remember, did you add to those areas? 
Dr. Sam Jejurikar: [00:24:35] I had a 250 CCS to each hip tip, and I generally find that my fat take in the hips is not as good as it is for the buttock. I generally tell people, I think if we're lucky and everything goes right about 50% of their fat will take in the hips.
and that's a rough estimate. and yeah. the hip have sometimes turn out great for me. Sometimes I feel like they look a little under corrected when I'm done. I've never over-corrected them to my knowledge, and had them stay that way. but it's, the skin is just very tight in that area. And I struggle with that a little bit.
Dr. Sam Rhee: [00:25:03] I feel the same way with you. I always. feel that area so tight. So the volume is hard to retain. I never over-correct, I always get some improvement and most patients notice that it's better, but to really, you really have to be, it's a balance between being overly aggressive, but, trying to get the result that you really want there.
So that's a tough one, but, I do a lot of that and that's always a challenge, for me as well. 
Dr. Sam Jejurikar: [00:25:29] Yeah. 
Dr. Salvatore Pacella: [00:25:30] That's great. excellent result, doctor, Jejurikar fantastic as usual? 
Dr. Sam Jejurikar: [00:25:35] thank you very much. And I think this is a, this leads to just a great discussion in general, mommy makeover, even, when we're talking amongst ourselves, we're not exactly sure what procedures we're going to offer a patient.
The key is a, see a good plastic surgeon who really tries to identify what it is that the patient's looking for. And then to individualize it. and I had another case, but we're, we'll say that for another day where it was essentially someone who looked very similar preoperatively and we did something very different to achieve what their goals were.
And if you're a patient and you are, trying to find a surgeon that can do a mommy, make a referral, you make sure they understand what your goals are, what it is you're looking for, and that they individualize the plan. And they're really listening to you for what it is you're hoping to achieve for this patient.
I've talked before about 3d imaging and how much I like it in my practice. We did 3d imaging of the breast to show what a larger implant would look like relative to what a breast augmentation, and a lift with a smaller implant might look like. we could simulate the scars with that as well.
And it was a good discussion overall, that helps her go in one direction. 
Dr. Salvatore Pacella: [00:26:37] That's great. Yeah. wonderful. I think we've reached our time here. So once again, signing off from, New Jersey Dallas and San Diego, wonderful discussion.