Latest / Alabama The Beautiful: The Eastern Shore Cosmetic Surgery Podcast / Mommy Makeover Made (Mostly) Easy [Part 1]
Transcript
- Announcer (00:02): You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis. Kirstin (00:09): Hey, Dr. Koehler. Dr. Koehler (00:12): Hello, Kirstin. How are you? Kirstin (00:13): Good. How are you? Dr. Koehler (00:15): Fine, fine. Kirstin (00:17): Okay. You know what we're talking about today? Dr. Koehler (00:20): I do not. What are we talking about today? Kirstin (00:22): Mommy Makeovers. Dr. Koehler (00:24): Okay. Kirstin (00:26): So I'm going to start off reading a review from a patient. Okay. You ready? Dr. Koehler (00:30): Yes. Kirstin (00:31): She says Dr. Koehler and his team answered all my questions and concerns, gave me the lowdown on all options available and put me at ease with the surgery before going in. I'm continuing to heal and I'm beyond happy with my results thus far. I've already recommended Eastern Shore to others who are in awe of my experience in results after having two C-sections, one that abscessed open in the normal wear and tear of pregnancy and childbirth. Being able to look in the mirror again and feel confident in who I see has been the best part of having my procedure. Isn't that sweet? Dr. Koehler (01:05): That's great. Kirstin (01:05): Yes. Dr. Koehler (01:06): I'm so glad my mom wrote that. That's so nice. Kirstin (01:12): What are some issues that you have seen from these teeny tiny little women's bodies growing these big giant babies inside of them? Dr. Koehler (01:24): Well, I mean, I don't know that it's necessarily that you have to be teeny tiny and have a big baby. I mean, this is just all part of what happens with pregnancy. Yeah. The common things that we see is obviously to make room for the baby, your abdomen has to stretch and typically the end result is the six pack muscles, the rectus muscles. There's a little sort of fibrous connection between the paired group of muscles, and that tends to separate to make room for that baby as it gets bigger. And then after delivery, those muscles don't necessarily come back together, and so there can be a gap between those muscles. And then the other thing, of course, the skin stretches out with pregnancy and once you deliver the baby, the abdominal skin, depending on your skin elasticity, depending on your age, and a lot of other factors, genetics, some people, their skin contracts down pretty nicely, but other people during pregnancy, you'll see they've got heavy stretch marks. Dr. Koehler (02:28): Skin doesn't tighten up after the delivery. So the two kind of most common things we see with the abdomen after pregnancy is skin laxity and muscle separation. And to really kind of get a good idea of the muscle separation, I'll sometimes have women sit in a chair just on the very edge of the chair and lean back and ask them to pick their legs up off of the floor. And when they do that, you'll see when they have muscle separation, it almost looks like a V in the center of their abdomen because there's not that connection between those two muscles. It bulges right in the center. And so that's what we typically are repairing as part of a tummy tuck is bringing those muscles together and tightening the skin. Kirstin (03:15): So do you think that most women know they can get these types of things fixed? Dr. Koehler (03:19): I think people are more aware now than they ever have been, but yeah, sometimes people don't really, they're not really sure what they need. And I would say a lot of people come in with the hope that they don't need a tummy tuck, but they're thinking, well, maybe I can just get liposuction. That's probably the most common thing that I see. They're like, yeah, I think this is mostly fat. And really, yeah, some cases there can be fat there, but most often it's the two things that I mentioned, which is skin laxity and muscle separation, and there's just no amount of working out and dieting that's going to correct those problems. Kirstin (03:55): Okay. So when we say mommy makeover, what exactly does that mean? Dr. Koehler (04:02): That term is so, I don't want to say overused, it's used a lot, but it means so many different things to so many different people because I mean, I guess really what the term is designed to say is like, Hey, I want to restore what I had prior to having kids. Now again, that can mean different things for different people. So for some women after children, whether they breastfed or not, maybe they lose volume in their breasts. So it could mean a breast augmentation, but they may also have droop. So then it could mean a breast augmentation and a breast lift. And if they have the laxity in their abdomen, it could mean a breast lift, a breast augmentation and a tummy tuck, and then maybe it could be liposuction of their flanks. I mean, there's lots of different things that kind of fall into that category, but basically what we're referring to most often when people refer to a mommy makeover is getting the breasts and abdomen back to the way they were prior to kids. That's what most people refer to it as. But it means a lot of different things. It's not a procedure, it's designated to address those two areas primarily. Kirstin (05:11): So should you be sure that you're finished having kids before you consider some procedures like this? Dr. Koehler (05:19): I mean, ideally, yes, but I mean there's lots of different situations. So mean we come across this all the time where maybe somebody has one or two children, but now they're divorced and they want to look good and they're getting back into the dating scene and they're not sure that they may or may not have more children with this person that they may potentially meet. So there's a lot of decisions to be made. And so with the breast surgery, if it's something like, oh, getting a breast augmentation, well, that's no problem. I mean, you can do that and if go on to have more kids, it won't typically affect breastfeeding. So that would be okay, you could do a breast augmentation and if you need to redo it after having more kids, okay, that's fine. But if we get into things like breast lifts and tummy tucks, then it gets a little trickier because when we do a breast lift, we are cutting into the ducts of the breast. Dr. Koehler (06:14): And can it potentially affect the ability to breastfeed? Maybe, nobody can really say for sure, but it certainly is possible that it could affect that. And so if that's important to you being able to breastfeed, that might be a consideration. And then for instance, with a tummy tuck, if we tighten those muscles and tighten the skin, it's not that you can't have kids, again, you certainly can. It's just that if you get pregnant again, and then let's say you go, well, I'd like to do another tummy tuck, you may not have enough skin laxity to pull that tight again. And so it could affect the ability to get an ideal result. So it's not a black and white answer. There's shades of gray here. And so certainly we do breast and tummy surgery on people that may potentially have more children, but ideally, yes, you'd like to reserve that to when you're done having kids. Kirstin (07:05): So if I were a patient thinking about doing all these multiple surgeries, how much can I have at one time? Is there a certain amount of time that you want your patient on and off the table? Dr. Koehler (07:19): So there's lots of different things that as a surgeon that I look at, and time is one of them. So ideally for outpatient types of procedures, we like to keep it to six hours or less. But time is just, again, one variable. I remember back in the days when I was doing some big trauma cases and stuff, I remember some 10 and 11 hour surgeries that we would do. Of course that was necessary surgery, it wasn't elective, but the longer you're on the table under anesthesia does increase your risk for things like getting a blood clot in your legs. So that's why we want to try to limit the length of time, but there's other things that come into play. So it's like, what's your general health if we're doing liposuction? So this is a thing I talked, I lectured to other doctors, we talk about this, is that what would be safer to take off three liters of fat off of somebody's abdomen or to take off a liter of fat off of their arms, inner and outer thighs mid back and flanks? Well, in the first scenario, I'm taking off more fat, but in the second scenario, I'm taking less fat, but I'm creating more tissue trauma to multiple areas of the body. And so anyhow, multiple procedures, multiple areas of trauma, can all these things impact how long we're going to or how many procedures we're going to do? I hope that's not too confusing. Kirstin (08:49): Well, so when we're talking about these types of procedures, is there ever a time when you would separate a breast and tummy procedure or is that something that you would prefer to do together? Dr. Koehler (08:59): Well, I mean, so for the convenience of the patient and the doctor really, I mean, if I can do it all at once, I absolutely want to do procedures all at once. Don't want to separate them. I want one recovery. Patients don't like to have multiple recoveries. It's easier for me, I can take care of business and get them taken care of. But in the event that I don't think if there's too much, I just think that's too big a surgery, there's too many risks for complications to do it all at once, then I'll separate it. But definitely, I mean, it's not unusual for me to do a breast lift and a tummy tuck and even a breast implant all at the same time, but it's on a case by case basis. So Kirstin (09:42): If you took a guess, do you have a certain amount of patients that choose only a breast lift or lift with implants versus just people who are candidates for just a straight augmentation. Dr. Koehler (09:54): Again, each scenario is different. So we see a lot of people that would benefit from a breast lift and augmentation. I think you may be asking a little different question here, but there are times where I won't do a breast lift and an augmentation at the same time, and that is a whole separate issue. And that has nothing to do with the length of time of the surgery, but more to do with the patient anatomy. So for instance, maybe it's a patient who's lost a lot of weight and I'm going to be moving their nipple a really long distance with the breast lift and maybe their tissues are kind of thin and not really good. Well, I may choose in that situation to just go ahead and first get their breast lifted and get everything in the right position and then come back at a later time to put the implant in. Dr. Koehler (10:38): So there's reasons why we sometimes will stage things and I'll share a story. I actually had a patient, this is not too long ago that came in, was in a follow-up, and I had just done her first stage, which was her breast lift, and she's got to wait three months and then we're going to put her breast implants in. Well, she was in the waiting room and there were two other women in there that I had just recently operated on that I did their implants and their lift at the same time. So they're all three talking in the waiting room. And so when this girl finally comes back for her appointment, she's like, I was just in your waiting room and I just met two of your patients that you did the implants and the lift at the same time. And I don't understand. And I'm like, we talked about this. I mean, not everybody's the same. I don't just sort of go, I like you, so I'm going to do it at the same time, and I'm not so sure about you. Anatomy is different and there's a lot of different factors, and that's why you got to listen to your doctor. And sometimes getting other second opinions, sometimes somebody says something and you might get somebody that tells you something different. But that's where you've got to sort through the pros and cons of all that. Kirstin (11:37): Well, and people read all these things on the internet too, and they're like, well, my doctor wanted to separate this into two surgeries. He just wants my money. But really that's not the case. It's for your benefit. Dr. Koehler (11:48): Well, I will tell you that I never separate a surgery based on a financial decision that is, that's not in the equation. I mean, the only time it would be in the equation is the patient couldn't afford to do it, and then we separated because we're like, okay, let's do this. You can afford this now. But I don't sit there and go, oh, if I do another surgery, maybe I can make a little extra money. It is really has nothing to do with that. So yeah, those are all discussions that you have. Kirstin (12:11): So if a patient is sure that they don't want to do implants, are there ways of using their own tissue to create fullness? Can they still get fullness with just a lift? Dr. Koehler (12:22): Yeah, there's certainly been techniques described and people to try to auto augment the breast using your own breast tissue. Those techniques don't really hold up, but a breast lift. And I actually, I jokingly say to my patients that I really don't like the term breast lift because I think in a lot of women's mind, it's like they visualize I'm taking their breast and I'm lifting the entire breast to a higher spot on their chest. And I tell them, look, it's really, I'd rather call it a sagging procedure or a nipple relocation procedure because really what we're doing is your nipple is let's say below the crease of your breast, we're repositioning it to a higher area and then we're getting rid of the sagging skin and breast tissue below. But what you don't get is increase in the fullness in the upper part of the breast. Dr. Koehler (13:13): And so to achieve that, typically we will always talk to any patient that says, I want a breast lift. We will talk to them about implants. And I think this is an important point because I always tell people, we're not here to talk to you about implants to try to upsell you an implant. What we're here to talk to you about is what you're visualizing in your head and what you want to achieve, which a lot of times is upper pole fullness, which we just can't get by doing a breast lift. So when we start talking to you about breast implants, that's why it's not like, oh, he's trying to do another procedure. Now, fat grafting is something that also it comes into the discussion. And I guess I would just answer that question in the simplest terms, which is this, if fat grafting worked really well in the breasts, why are we not doing it? Dr. Koehler (14:04): I mean, there's lots and lots of people that have enough fat to do fat grafting to the breast, but why wouldn't that be the first option then if you have enough fat? And the reason is, is it's just it's not predictable. You can get fat take, but it's not always what you think it's going to be. So the nice thing about an implant is if you say, okay, I'm going to increase your breast by 300 ccs. We know predictably you're going to get a 300 cc increase in volume, but if I put 300 ccs of fat in there, maybe only a hundred of it stays. And then I go, okay, well we got to do a second and maybe a third time to get you where you want to be. The patient satisfaction rate with fat grafting in the breast is not high. Yes, it's sometimes used as an augmentation to maybe help build up some cleavage, but it's usually done in conjunction with implants. Dr. Koehler (14:56): And quite frankly, the history on fat grafting the breast is not, I mean, if we go way back, it was really considered malpractice to put fat in the breast because it can cause microcalcifications, cyst formation, all sorts of things that can appear abnormal on a mammogram. So then you go get a mammogram, and then they're like, oh, we got to do a biopsy. And you're like, why do you have to do a biopsy? Well, you've got these abnormalities there and the abnormalities are just post-surgical changes from transferring fat in your breast. So it's not all perfect. And I mean, I'm not against fat grafting to the breast, but it's not ideal. Kirstin (15:37): So we were talking about lifts just to tell a potential patient about recovering and scarring and stuff like that. Where would their scars be for a lift? Dr. Koehler (15:45): Let me tell you that. Kirstin (15:46): Show me. Dr. Koehler (15:47): I will show you the scar. Hold on. So the incisions are typically either they're around the nipple and a vertical scar from the nipple to the crease of the breasts. Some people call that, it's called a vertical mastopexy. Some like lay people will call it a lollipop lift. And then the other main lift is the incision around the nipple with a vertical incision from the nipple to the crease, and then a horizontal incision that is in the crease of the breast, and that's the anchor lift or a Weis pattern lift. So those are the two most common. Now there is one other type of breast lift, which I am not a fan of, and it's where the incision is just around the nipple, and that's called a benelli lift or just a peri areolar mastopexy. And I've had a lot of women over the years ask or request for that lift because they are bothered by the potential visibility of a vertical scar on the bottom side of their breast without being able to draw and explain all this to you. Dr. Koehler (16:58): It really, when you do these circum areolar lifts, you make an incision inside the nipple and then there's an incision made around a bigger incision to move the nipple to this higher location, and then all the skin has to get bunched up around that nipple. And inevitably what ends up happening is that it stretches out and then you end up with this areolar that is like baloney. It's like this big wide areolar. And people try using permanent sutures and things to prevent that stretching. And I can say occasionally I've seen a few that actually look decent, but I could say for every one that I've seen decent, I've probably seen like 20 that don't look good. So I don't do that lift. I'll do the vertical or the anchor. Those are the most common. Kirstin (17:50): Is there a certain amount of time that we should wait between having kids and having a mommy makeover? Dr. Koehler (17:56): I think you should do it right away, Kirstin. Kirstin (17:58): Right away? Should you wait eight years? That's what I did. Dr. Koehler (18:04): No, even if you aren't breastfeeding, you're breasts becoming engorged, you may produce milk. And if we're going to do any kind of a breast procedure, we want that milk to be dried up. And so typically that's about, I usually say four months from the time you stop completely, a hundred percent stop breastfeeding. And sometimes people require medications to help them get their milk to dry up, but you don't want to do a breast surgery while you're still lactating. Because when we make those incisions in the breast, like I talked about, and we're cutting into the duct of the breast, if there's bodies producing milk, I mean that starts to leak into your surgical sites. It can get infected. It's just so you can't do it. So breast augmentation, breast lift, minimum four months from the time you stop breastfeeding. And really, I mean, I don't know that there's a timeframe per se, but I mean when you're going to do a tummy tuck, it's a couple weeks of recovery and you've got a baby that you got to take care of. So it depends on what kind of support you have at home. Do you have somebody there? So a mommy makeover may not happen for some people until their kids are old enough that they can actually have somebody that is there to help them with their children. So it may be a few years, but certainly I've done mommy makeovers on people that they have children that are a year old or younger, but they've got lots of support. So it just depends. Kirstin (19:31): Yeah. When patients here, if I talk to patients about a tummy tuck or whatever, and they're like, how is recovery, I always, always start off with, I don't have little kids. My kids can fend for themselves. So I feel like that probably plays a big role in recovery. If you have a 2-year-old running around that wants your attention all the time, your recovery is probably not going to be as easy as if you have teenagers or, you know. Dr. Koehler (19:57): Yeah, I mean, I think it's hard whether just having kids and having a family and having to do all the things that you have to do unless you have completely independent, fully grown children, there's stuff you got to do. So yeah, I think definitely you need to have support, husband, friends, family, whoever it is that's going to be there for you to help you recover. That's going to be a really important part. Tummy tuck, typically, most people are feeling decent after a week. I won't say they're feeling great, but they're feeling okay. And typically by two weeks you might not be standing up perfectly straight, but you can drive a car. You're typically off the strong pain medicine, you're moving around and doing things. And then at six weeks usually was what I tell people before, you can do heavy exertion, maybe try to go back to the gym or do any kind of heavy lifting. So you're going to need help for those first two weeks, for sure, the first week, but maybe two, and then after two weeks, yeah, you should be pretty good at that point. I mean, even if you have young children after two weeks, I mean, you'll be probably pretty tired at the end of the day, but you could probably do it after two. Kirstin (21:11): When we're talking tummy tuck or abdominal surgeries. What about old C-section scars or hernia scars? Dr. Koehler (21:20): Well, C-section scars, those will be gone because we'll typically place the tummy tuck incision below the existing C-section scar, and then when we remove all the skin above that, the scar goes away with the removal of the skin. So you'll get rid of your C-section scar, but you're going to get a longer tummy tuck scar. So those scars are just gone. Kirstin (21:43): Yay. Dr. Koehler (21:45): Yeah, and actually it kind of brings up something that I talked to a patient today about, actually. So she said, well, will my tummy tuck scar look or heal exactly like my C-section scar because my C-section scar healed really well? And I said, well, yes, that's an indicator, but exactly, that's not how it works. And this is why. So when you have a C-section, you've got a baby inside, they take the baby out and all they're doing, they use that incision as access to get to the baby. But when they're done, there's no tension on that skin and the skin is closed together, and that's that. But in a tummy tuck, we're removing a big section of skin, and then we're pulling it down and we're reattaching it to the skin of the pubic area, and it's under tension. And because of that, any incision or that is under tension is not going to heal as well, typically as an incision that has no tension. Dr. Koehler (22:45): And there's things that we do surgically to help relieve some of the tension on the skin edges. But the point is, is that it's not a completely tension-free closure compared to something like a C-section. So sometimes the tummy tuck scars can heal a little wider or a little thicker than what you would typically see with a C-section scar. But there's a lot of things we do to help make those incisions look really good. And typically they're low enough and they're hidden, and they do look good. It sometimes takes a year, year and a half for them to really fade. Kirstin (23:12): So are there different types of tummy tucks? Dr. Koehler (23:17): Yep. There's the tummy tuck that everybody does, and then there's Dr. Koehler tummy tuck. Kirstin (23:21): Yes. Dr. Koehler (23:23): <laugh> I'm just kidding. Kirstin (23:25): Yep, that's right. Dr. Koehler (23:25): So there's really kind of, there's several tummy tucks. The two most common that people talk about are a mini tummy tuck and a full tummy tuck. And so a mini tummy tuck is typically suited for a patient who says, I love the way my upper abdomen looks. I have no problems there, but maybe they had a C-section and they've got some skin laxity just above the C-section scar, and they're like, I don't like how that looks. So a mini tummy tuck, we can remove just the skin, like we make an incision below the C-section scar, and then we can remove about half the distance between where the C-section scar is and the belly button. That's it, no more. And then we can remove that skin and tighten it. So if your problem is just a little bit of loose skin just on the lower abdomen, we can do that. Dr. Koehler (24:17): However, it's really not going to address muscle separation above the belly button. Sometimes we can sneak up there and do that. I won't get into all the details, but typically it's not to deal with muscle. Big muscle separation requires a full tummy tuck typically. So the full tummy tuck, the incision really kind of goes from hip bone to hip bone. It's a little bit longer incision, but it's still down low. And then there's an incision around your belly button. We do not make you a new belly button. You keep your same belly button. Now, yes, we have to suture it in place, and there's things that we do to try to make it look more natural, but it's not like we create it. It's the same one you were born with, but then the skin is pulled down and we make a new opening for your belly button, and we remove the excess skin. Dr. Koehler (25:00): And so the goal, hopefully, if there's enough laxity, is to remove all the skin from the pubic area to just above the belly button. All that skin gets removed. That's a full tummy tuck. And then there's one other, well, actually there's several other types of tummy tuck, but the other one that might be referred to is called alelee tummy tuck. And that's one where not only do you have the horizontal incision, but you have an incision that goes from really where your ribs end or start and all the way down to your pubic region. So from xiphoid to pupa. So you have a vertical incision that is, if you already have a vertical scar, we will sometimes use that because we can now not only bring the skin down this direction, but we can narrow in this narrow in the waistline. But we wouldn't do that unless you already had a scar. Dr. Koehler (25:53): Or sometimes in massive weight loss patients where there's so much skin laxity where we really can't get it as tight as we want by just pulling down. So we got to pull both directions. And then there's one other, it's called a reverse tummy tuck where the incision is made up underneath the breast. I don't like that procedure. I've never seen that look good. But instead of pulling down, you're lifting up, but you end up with a scar that really kind of goes all the way across your chest. And that would be for somebody who just has laxity in the upper abdomen and really none in the lower abdomen. So anyhow, the main ones are full tummy tuck and a mini tummy tuck. Kirstin (26:26): Are there certain limitations for, well, really any types of surgeries that you offer, but mainly tummy tucks? Are there BMI restrictions or anything like that? Dr. Koehler (26:36): Well, there's not really A BMI restriction, but I can tell you that I guess I have restricted the cases that I'll do adominoplasty on to people who are under a BMI of 35. And the main reason is this, the higher your BMI, the higher chance for infection, the higher chance for wound separation where the skin opens up and the higher chances for things like blood clots in your legs. So your complications just start to go up and up and up and up as your BMI goes up. So it's not that you can't do it, and we do something that it's a tummy tuck, really, but people call it a panniculectomy. And let me tell you the difference between a tummy tuck and a panniculectomy. A panniculectomy by definition, is basically the incision goes from hip bone to hip bone like a tummy tuck. Dr. Koehler (27:30): But then what we cut off is just anything that's hanging below the pubic area. So if your belly button happens to be below your pubic area that gets cut off, everything just gets cut off and it's done. This is a procedure that is covered by insurance typically, and it's truly done for health reasons where people have chronic fungal infections and they just chronic skin irritation because they've got this panis of skin hanging over their pubic area. But anyhow, panniculectomies are typically done on heavier patients with higher BMIs. So maybe their BMI is 40, 45 or even higher, and it's done for medical reasons to just basically allow them to keep that area clean and not get raw and irritated. But those patients, it's being done for medical reasons and will accept a little higher risk for wound breakdown and blood clot because we're doing it for their general health. But when we're doing it electively, because, hey, I just want to look better, if your BMI is over 35, you really should get, some people do lower. Some people will say 30 is their maximum for tummy tuck, but ideally you'd like to be below 30. That's where your risks are going to be a lot lower. But 35 is my cutoff. Kirstin (28:46): I want to rewind because we were talking about belly buttons and I didn't mention belly button king, Dr. Koehler (28:52): <laugh> Whatever. Kirstin (28:53): I can't believe that. So I really feel like I should tell potential patients of yours and anybody else, if you're considering a tummy tuck, you got to look at the surgeon's belly buttons, right? Dr. Koehler (29:05): Yeah. Well, yeah, belly buttons are important. I mean, Kirstin (29:08): I feel like that's important, especially if you're going to wear a bikini. You want to have a good belly button and you're the belly button king. Dr. Koehler (29:14): Well, I know it is important to patients because that's the one part that if it's anything's going to be visible, that will be the visible part. It's a lot harder to do than what people think. And of course, like I mentioned, we don't create a new one where having to work with what you've got sometimes what we've got makes it easy to create a nice looking belly button. And sometimes because of weight gain, weight loss, multiple pregnancies, the belly button gets stretched out of shape, and it's hard to create the look that we're going for. So again, there's lots of things that sort of determine that outcome. But definitely I do pay a little extra time on the belly button closure and how it looks, because I do understand how important that is. I've heard people say, oh, I came to see you because I like how your belly button's looking. So anyhow, it is an important part. Well, it's all important, really. We want it all to look good, but that is the visible part. I did have a patient recently say, listen, I don't really need you to make me a belly button. If you want, just leave it blank there. I was like, really? You don't want a belly button? So I guess you can go without if you don't want it. Kirstin (30:19): I've seen that on the blogs and the Facebook pages. Some people are like, no, I went without a belly button. I'm like, but if you saw the belly button king, you wouldn't be saying that. So we talked a little bit about stretch marks. Do stretch marks play a role in any of this, or are you able to get rid of stretch marks? Dr. Koehler (30:37): If they're in the area that's planned to be removed, then yes, we'll get rid of them. So typically, like I said, any stretch marks that are below the belly button stand a chance to be removed. But any that occur above the level of the belly button, those will all still be there because I mean, we still have to stretch that skin down and bring it down. Thing that's difficult with stretch marks and really only for people who have really, really heavy stretch marks. Their skin is really thin in the stretch mark skin. It's paper thin sometimes. And so sometimes the skin closure can be a little more challenging. They can have some healing issues. But really for the most part, the average stretch marks that we see, not the heavy wide, thick stretch marks that I'm referring to, but the typical stretch marks are, even if we can't remove them because the skin has been tightened, they tend to look better. They don't have that sort of, I don't know, that relaxed, wrinkled appearance that they sometimes do. Kirstin (31:38): And as with surgical scars, we can do all kinds of things like lasering and microneedling to help ease the appearance of those stretch marks as well. Dr. Koehler (31:48): Yeah, I mean, there's several things in the cosmetic world that are really difficult to treat. I always say like cellulite, stretch marks and fine lines around the mouth. I mean, those three things I see on a daily basis and people complain about what can you do to fix it? And there is no cure. There are things that we can do to help improve those things, but sometimes you're stuck with some of that stuff. Kirstin (32:11): So we talked about mommy makeovers typically include fixing the tummy and something to do with breasts, whether it be lift implants or a combination of both. Are there other things that you typically see people like to add into those little mommy makeovers? Dr. Koehler (32:28): Yeah, like liposuction would be another one. So either inner and outer thighs, maybe love handles mid back, and then sometimes fat grafting. So adding volume to the buttocks. And sometimes it's not really about size. Some people just associate putting fat in the buttocks to increase the size, but there are many times where adding volume can be extremely beneficial to just improve shape. And we talked earlier about how I'm not a big fan of fat grafting in the breasts, but fat grafting in the buttocks is a little different. It's still not a hundred percent predictable, all that stuff, but definitely the fat does a little better there than it does in the breast. Now, there's some other risks that go along with that, and that's a whole nother discussion, but you want to make sure you've got a surgeon that knows how to be safe and doing that procedure. But it's actually a very good procedure. And I certainly in that circumstance, I would much prefer putting fat in somebody's buttocks than I do putting a butt implant in. It's putting your own fat in is a much better choice, in my opinion. Kirstin (33:36): Do people ask about butt implants? Dr. Koehler (33:39): Oh yeah. Kirstin (33:39): Typically? Dr. Koehler (33:39): Well, it's not popular. And so the people that really are the best candidates for butt implants are people that are thin, that don't really have much of a butt, that don't really have fat to graft, and then you can put an implant in. I quit doing that procedure. It's just not a procedure that I did frequently, and so I kind of leave that to the people who do them on a regular basis. But yeah, it's an option. Kirstin (34:04): Little booty fat grafting can turn into art. Dr. Koehler (34:09): Hm-hmmm. Kirstin (34:09): Okay, we have a part two to our Mommy Makeover episode. We're going to talk about recovery, so tune in for that if you want to learn about Mommy makeover recovery. Dr. Koehler (34:18): Awesome. Announcer (34:19): Got a question for Dr. Koehler? Leave us a voicemail at Alabama the Beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you'd like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.