Second Pregnancies and Plastic Surgeons

If you're looking for pictures, ain't gonna happen. I am not ready to go there again. If you're curious how I fared and what I learned at the plastic surgeon this week, read on my friend.



Second Pregnancies



My diastasis is unchanged as a result of my second pregnancy. As in, it is not better and it is not worse. I actually felt somewhat pretty while I was pregnant because it was the first time I could comfortably wear t-shirts and tank tops in almost two years.



My weight gain with Lola was pretty standard -- 30 pounds -- and even though I carried the majority of that weight in my belly while I was pregnant, the strain of her growing inside me did not create a larger gap between my muscles. I did however "pop" much faster and it seems as though I have another hernia as a result of the pressure of her pregnancy on my insides.



Post-Partum



I was back down to my prepregnancy weight at 16 weeks postpartum. Now, at 23 weeks postpartum, I have actually lost another 5 pounds bringing me down to my pre-IF weight. If it wasn't for my FUPA I would feel pretty good right about now. Losing more weight hasn't done anything to bring my abdominals in and my belly button is still detached. Although, as a result of the weight loss I do wake up with a nearly flat stomach. However since I have more than 5" of separation between the muscles, the fascia stretches throughout the day with normal consumption of water, coffee and food. There is no correction for muscle laxity that is this severe.



I want to repeat that again, because I get many emails about this. And I get where people are coming from because they are frustrated and sad and angry and hopeful that there is a non-surgical solution. So, once again...



THE ONLY CORRECTION FOR MUSCLE LAXITY THIS SEVERE IS SURGICAL.



Second Plastic Surgery Consult



On Tuesday I had my second consult for abdominoplasty. My first consult was at 5 months postpartum from the twins. So the timing is exactly the same, I just have one more pregnancy under my belt. The first surgeon was a tan, self-righteous prick with an awful bedside manner. This new guy that I saw was *nothing* like that (thankgod).



The staff was wonderful, he was wonderful. Many of them had also undergone IVF which made me feel a sense of camaraderie and connectivity on a personal level. Which, let's be honest, is helpful in being comfortable with choosing a facility.



I do not have enough extra skin to perform a traditional abdominoplasty wherein the surgeon would cut horizontally, repair the abdominal muscles, reattach the belly button, drape the skin that was previously above the belly button down to the surgical cut line and create a new hole for the belly button to stick through. My skin is loose from my stretch marks, but I do not have an excess of skin. As a result, I have two options for corrective surgery, one is more invasive (if that's even possible) than the other but it will also yield better results. This surgeon in particular automatically does liposculpting as part of the procedure to help with the overall post-surgical aesthetic.



Surgical Option 1



Cut horizontally and cut the belly button from the stem (a procedure called floating the belly button). This allows the surgeon to separate my skin tissue from the muscle and access my upper abdominals to repair the separation. He would then reconnect my belly button to the stem and remove any excess skin from below the belly button to the surgical cut line.



With this option I would keep all of my stretch marks that were above my belly button. Which is fine by me. This procedure is also slightly less invasive. Also fine by me. However, because I have stretched and looser skin above my belly button once my abs are pulled back the stretched skin will be more pronounced and may even look bunched. The effect will be somewhat loose skin above the belly button and tight skin below. Cosmetically speaking, this isn't the best option.



It would have been if my stretch marks had not gone all the way up to my rib cage. But with the steroid cream I was on as a result of my PUPPPS my skin broke wild and free around 33 weeks. (I am certain it would have broken regardless, but the steroids thinned my skin dramatically and it broke with reckless abandon within a week of using it. Then again, I probably just have shitty genetics and blaming steroid cream makes me feel better.)



Surgical Option 2



Cut horizontally, cut vertically up to the belly button and cut around the belly button leaving the belly button and stem in tact. Stitch the belly button back in place (right now it is herniated), repair the abdominal separation, pull the skin down to the surgical cut line over the existing belly button and create a new hole for it. That leaves a circular hole and vertical cut at the surgical line. The surgeon would sew the hole (that was from where they cut around my belly button) together and sew the vertical line together as well.



So I will have a roughly 1.5-2" vertical scar in addition to a horizontal scar with this option. The scar is a scary thing to me since I have never had a major surgery and I have no idea how my stomach will heal. However, cosmetically this will achieve the best look overall.



Logistics



The surgery will take approximately 2.5 hours and is done as an outpatient procedure. The surgeon uses twilight anesthesia, which I liked because it means I will not have to be intubated. After the surgery is complete I go home wrapped up tight with a pain pump and two drains. The stitches are all internal so there is no need to come back and have them removed, there is just surgical tape that will fall off over time. The drains come out between the first and second week.



As for the pain pump, I don't remember how long it stays in for. It is novocaine that automatically disperses over the surgical area throughout the day to help with pain management, thus alleviating the need for the use of excess pain narcotics. It is $275 extra and worth every penny, since the pain meds will constipate you and who really wants to strain to take a shit after being sawed in half? Not this girl.



The first three days will be the worst in terms of the pain and the WTF was I thinking doing this? type of in your own head questions. After a week I will be able to be relatively mobile. However the doctor told me that I would need to take it easy for the first two weeks as much as possible. He also told me that the more active/on your feet you are for the first 4-6 months the worse that your swelling will be. I guess there are issues with the surgical sight retaining fluid from overactivity. I've read about this through various support sites as well.



Cost



My umbilical hernia will likely be covered by insurance, shaving nearly $3k off the total cost of surgery. The remainder will be out of pocket. For the surgery, operating room time, anesthesia and pain pump the surgery will cost $7800.



Typically the second option, which is the one I am electing to do, would cost more but since I am a skinny bitch he doesn't think they will need to do liposculpting with the procedure. So the extra time with the skin issues offsets the time gained with eliminating the liposculpting and in the end it's a wash.



My insurance company does not cover diastasis repair as it is considered a cosmetic procedure.



Next Steps



I honestly loved this surgeon. I had the pleasure of being able to talk to another one of his tummy tuck patients who is a friend of a mutual friend (if that makes sense?) and she raved about him and was very happy with her results. And this particular surgeon is married to my old pilates partner. I had no idea, I found out right before doing my consult there. I am 99.7% sure he will do my surgery when the time comes. But because this is a big decision, I am meeting with two other surgeons in my area just to make sure I am choosing the right person.



When the Time Comes



So what the hell does that mean? I really have no idea. In my little type-a head I have a plan, but like all well-laid plans it is destined to fail miserably. But since I have the plan mapped out I might as well share it with all of you.



I plan to nurse Lola through to a year (i.e. October). Then there is a series of craziness that ensues at our house. Joe's birthday, Lola's birthday, Halloween, Thanksgiving, Christmas, and the twins' 3rd birthday. I host the twins' birthday parties on MLK weekend because it is a holiday (i.e. long) weekend and so it makes travel for our families easier since they are all out of town. I am hoping to have surgery the week following the twins' birthday party.



The timing will be good because all of the holiday/birthday hustle and bustle will be over with and it'll be in the middle of January so hunkering down in sweatpants and compression garments won't be too unbearable (all things being relative). I am hoping to convince my mother-in-law to stay after the kids' party through President's Day -- so 2.5 weeks total -- to help take care of the kids. Joe will be able to take a the week of my surgery off as well. By week two I should be partly mobile and between him at night and my MIL during the day, I should be all set.



Now onto the complicated part of all of this...

My last frostie. A 4BB blast vitrified on day 5. If we had multiple embryos we would be donating them to research. Because we only have one embryo it is not eligible for research donation. We will not consider donation to another family. Which leaves me with two options: an FET or disposal. Literally going to my RE's office and pouring my embryo down a sink myself, because the office does not dispose of embryos as part of their policy.



The problem is I've seen what a little blot on a paper like that can become. And it's not inconceivable that I could have one more child.

I feel like our family is complete. I feel like I am done with this phase of my life. I feel like I am ready to move on. But it's really not that easy. And then there's the little thing called my marriage that I need to take into account. Some days I am not sure it'll survive the life we're living already. Forget about bringing in another tiny human. I'm also not sure my sanity would survive.



Then again I am not sure my sanity would survive if I just tossed that embryo down the sink. Cause I am a what if kind of gal.



So That's That



Once upon a time ago, someone commented on this blog and asked me if I felt like I had defeated IF. I think it was right after I conceived Lola. The answer is a resounding NO! Because when you still have to make decisions like this -- whether to have more kids or dispose of an embryo, you are still somehow in the trenches. Not the childless ones, not those. But the ones where the decisions are still difficult. I am ready to be past this stage. So ready.



So there are a lot of what ifs and a lot of things to think about. But for now I know that I will have a few more consults, I will have surgery, surgery will cost me a small fortune, recovery will be a pain in the ass and I need to work on myself and my family before I jump onto another gurney -- be that one with or without stirrups.

Diastasis Physical Therapy

Note: I wrote this post on May 20, 2011. For some reason I never got around to publishing it, even though it was complete. Google searches on diastasis are one of the main things that bring people into my blog, so I wanted to push this post live. I did physical therapy for around 4 months after my twins were born. As soon as I stopped wearing my abdominal brace, my abdomen relaxed and went back to sticking out. The exercises did little to improve a tear as severe as mine. At some point in the future I will have corrective surgery. I have started a post discussing how diastasis has affected my current pregnancy which should be live soon. I hope that by documenting my journey others with similar issues are able to find some answers to their questions or insights about this issue, as there is not a lot online that isn't a sales pitch or marketing gimmick for an abdominal binder or surgical practice. I am blessed to have these issues, since they are a result of my beautiful children, but I still struggle with the changes I have undergone and how they make me feel about myself as a woman. I think this is only natural and I am not apologetic for my insecurities. 

__________________



Last Friday marked my first day of physical therapy for my stomach. I have two follow-up appointments scheduled, so I'm seeing the therapist every two weeks. She's given me exercises to do on my own daily, which I'll detail below, and I've been instructed to wear an abdominal splint 24/7.



In the 7 days since my first therapy session, I've managed to fit in the exercises five times. They aren't time consuming, or even what I'd call hard. But they do require that Joe is home to help mitigate fussy babies, and since he's had a couple of long work weeks and his MBA classes have started back up, well there hasn't been a lot of time for me to be alone. And at the end of the day I'm exhausted. But 5 out of 7 ain't bad. Right?



I definitely see an improvement in how much my stomach sticks out, but I can't tell if that's because I've been splinted for a week or if the exercises are helping. Or maybe both. I have a terrible fear that once I stop wearing the splints everything will fall forward again and I'll go back to looking 17 weeks pregnant again.



At 18 weeks postpartum, I have lost all of the weight I gained while pregnant. So that is not one of my issues. When I got to the therapist's office she looked over my stomach and had me do some moves which allowed her to check the severity of my diastasis. She told me that my abdominal separation is so severe that, while the exercises and splinting will help, the only fix for me is surgery.



I have two specialized braces. The Taut is the one I was told to wear for everyday use and the Tupler Splint is the one I was told to wear while working out. The only times I am supposed to take off the braces are when I shower and when I'm doing the prescribed exercises so I can connect with my body and feel where I'm supposed to be breathing from or pulling in from.



Hearing that surgery was my only option killed me. But after doing some research I've read over and over again that diastasis is correctable through splinting (which provides focused support to close that gap in the outermost abdominal muscle formed during pregnancy allowing the connective tissue to heal) and the prescribed exercises. So I'm holding onto the fact that I can fix this and I'm giving it time.



Here are the three exercises I was given to start with:



1.) Spinal Massage (also known as spine torture)

 

I have a 4" ball that I purchased from the therapist for this exercise. You start by lying on your back (lying down and sitting up you are to start on your side and use your arms to guide you like you would when you are pregnant) and placing the ball between your shoulder blades. Place your hands behind your head and let your head and elbows hang (don't hold up like you're doing a crunch). Knees are bent with feet flat on the floor. Let your body stretch over the ball focusing on closing your rib cage and pulling your ribs back toward your spine. Hold the ball in place until the muscles start to relax (approximately 30 seconds to 1 minute) then use your legs/feet to slide the ball down your spine in 1" increments and repeat the stretching/relaxing section by section until the ball reaches your tailbone. Roll to your side to release the ball and then allow yourself to lie flat on your back and relax the spine completely. Roll to the side and use your arms to sit back up.

{ the ball I purchased from the therapist }

The next two exercises are performed seated with body weight centered over the pelvis and shoulders back. Place your hands over your belly to connect with your breathing. I sit criss cross applesauce (aka indian style) on a relatively firm pillow. My butt is on the pillow and my legs are in front of it.



2.) 30 Second Hold



Begin with a belly breath, then exhale and contract the abdominals by drawing the belly button all the way to the spine. Imagine you are touching the spine with your belly button. Hold it here and count out loud for 30 counts. Do 5 sets of this exercise per day.



3.) Repeating Transverse



This exercise starts in the same position as the 30 Second Hold, however it is a pulsed contraction. Begin with a belly breath, exhale and draw abs to your spine. This is the starting position. Hold this contraction for a count and then release the muscles halfway out. Repeat this back and forth motion. Count out loud for 50 repetitions. Do 2 sets per day.



So those are my exercises. Wash, rinse, repeat. And never miss a day. One thing I really did appreciate about this woman is that she told me it's okay to be angry about what happened to my body and mourn the loss of it. That my children and my love for them is completely separate from my feelings about my body and what the pregnancy did to me. I needed to hear that. So many people have suggested that my frustration with my PP body is PPD or an eating disorder. I needed to know that it's okay to be angry that this is the result of my pregnancy the same way I am elated that Reese and Ryan are the result of my pregnancy.



Anyway, I have NO idea when I would get an abdominoplasty or if I would get one. You can't pick up your kids for 6 weeks post surgery and then there's the recovery afterward. So I need to get past baby #3 and then get through the first year or two of his/her life before it's even an option for me. I didn't have a section, so I'm upset about having a scar on my body from the surgery and I'm terrified of having surgery altogether.



It's been very hard for me to recover as a woman - I don't feel sexy and I'm embarrassed about my body. And not only has that taken a toll on me emotionally, but it's impacted the physical parts of my marriage as well. I need to get over myself. I know I do. But it's hard.



You can read more about my experience with diastasis here, here and here. 

Lose All of My Baby Weight and Rock a Bikini in Nantucket

What can I say? Some things just sound better on paper than they actually are in real life.



If I'm being honest, when I wrote that goal in February I really thought that I would be able to be back to "normal" (even if it was a new normal) by September. I didn't know anything about umbilical hernias or muscle separation and I figured my body looked like what most women's bodies would look like after having twins.



Now that I've had 7.5 months to recover and I'm a bit more educated about the realities of postpartum life, I'm happier with how I look in some ways and more frustrated with how I look in others.



How I'm Happier



Well for starters, I lost all of the weight. Go me. My postpartum shape isn't all that bad either. Everything, with the exception of my hips and my waistline, is right back to where it was before the babies were conceived. My hips are a bit wider so most of my dress pants pull horizontally in an unflattering way and my seriously skinny jeans only make it three quarters of the way back up my leg. In a lot of ways I look better than I thought I was going to once I realized my stomach was ruined.



How I'm More Frustrated



I cannot put in words how sad my belly button makes me. It sticks out and droops and is hooked. Even in loose shirts you can see it. Spanx help a little, but not a lot. I'm coming to accept my diastasis (for now) but it makes me very self conscious. It's hard to feel sexy - for myself, for my husband - with a beer belly.



Another Baby



I start BCP's for my first and final FET mid-September, with an anticipated transfer mid-October. We have discussed, but not yet decided, what we'll do if nothing survives the thaw or if the FET does not result in a pregnancy.



We will not do another fresh cycle (even limited fertility or SETs) because there are too many what ifs and we don't want to risk having more frozen embryos since it is our agreement as a couple that any embryo we create will be given a chance at life. Injectibles and Clomid cycles haven't worked for us in the past and it is my belief that the risk of multiples is higher with these types of ART than IVF. So this too is not an option.



Right now I feel like I am ready to be done trying to conceive if this cycle doesn't work. But I don't know how I'll feel if the cycle ends badly or results in nothing. So I'm reserving the right to change my mind.



One thing we did agree on is that if we do TTC on our own, we will only do so for a set amount of time and then move on. The liklihood of our infertility being cured by a single pregnancy is very slim, and I'm not willing to bang my head against a cement wall for too long.



Consultations and Next Steps



Exercise has done wonders for closing my muscle separation. I went from being able to fit my fist in between my abs, to only having a 3ish finger separation. Most of the exercise I've been doing is running and spinning. I, honestly, haven't focused much on the transverse abdominal work and I broke up with my PT after some of her comments.

At this point, I think my separation has healed as much as it can. As the day progresses and my muscle tissue relaxes, the separation becomes worse and my stomach becomes more distended. I believe the only correction is surgical.



So far I've consulted with a general surgeon specializing in hernia repair and a plastic surgeon. The general surgeon is able to laparoscopically sew together my ab muscles and repair/reattach my belly button. The post-surgery result would look something like this in terms of the size of the surgical holes and stitches.

However, the small holes would run vertically down my stomach (instead of horizontally) and I would have approximately 5-6 of them in total, plus a dime size opening for the laparoscope to the side of my belly button (as opposed to the top position in this image). My other option is to have a full tummy tuck.



Laparoscopy vs. Abdominoplasty



Both surgeries would repair my belly button and muscle separation. And both repairs (regardless of whether they are done by a general surgeon or a plastic surgeon) would be covered under our insurance, with a 10% coinsurance and the normal deductible fees. If I elected to do a tummy tuck, I would just pay for the extra OR time and surgeon's fees for skin removal.



Both surgeries have the exact same pain level and the exact same recovery time, since the part of a tummy tuck that is the real killer is stitching the abdominal muscles closed (not the removal of extra skin).

{ crazy belly button, fabulous skin and my linea nigra 

STILL THERE 8 months later }

{ belly button, which sometimes decides to 

fall into the grand canyon, and sexy skin }

With one surgery I end up with a giant hip to hip scar. With the other surgery I get stuck with all of my extra skin, which could look a lot worse than it does now once the muscles are narrow and flat again. Neither surgery will fully remove my stretch marks since they go up to my rib cage.



I still don't know what makes more sense.



What I Look Like Now



Since I know you're mostly here for pictures, these were the last ones taken at 32 weeks postpartum.

{ Taken first thing in the morning. Not too bad. 

Mostly a funky belly button. Not great, but livable. }

{ Taken in the early evening. My stomach is 

much more distended by this time of day. }

{ Opposite side, another morning shot. Again, not so bad. }

{ Opposite side, another evening shot. 

Looking 17 weeks pregnant. }

{ And a cutie patootie shot of my stretchies and my belly "button". }

So That's That



As far as pregnancies go, mine was textbook perfect. I ran, swam and took spinning classes until I was 32 weeks pregnant, when I was put on bedrest for slight cervical funneling. I gained 47 pounds total. I didn't indulge in fun treats or fatty foods. I thought if I did everything "right" I'd be okay.



Nearly 8 months later, I'm both shocked and amazed at how much my body has accomplished and all of the ways it has changed. My stretched out, saggy, sad looking stomach held two babies inside of it for 38 weeks and 3 days. They both arrived in this world weighing over 6 pounds. I wouldn't trade that outcome for the flatest, smoothest stomach in the world.



But I'd be lying if I said I hadn't hoped that I'd be one of the lucky ones with full term babies AND a flat stomach.

Plastic Surgery Consult

For the last month I have been seeing a postpartum physical therapist to help me navigate my diastasis. I have a whole post in the works on the exercises that I've been doing and the abdominal binders that I've been wearing, and I'll get to finishing it eventually.



The postpartum PT has reiterated over and over again that my diastasis is not correctable through exercise and that my only option is abdominoplasty (i.e. a full tummy tuck). Usually when she tells me this I start to cry and so then she suggests that I am depressed and recommends a PPD counselor. Um, no dickhead, I'm not depressed. You just told me that my stomach is so jacked that my only option is plastic surgery. What should be my natural response? A cartwheel?



So in an effort to save my sanity, or at least not throat punch my PT, I made a consult appointment with a plastic surgeon and that consult was this morning. Now - to be honest - I really don't want to have plastic surgery, I would rather live with a perfectly imperfect god-given body than a surgically imperfect body. Additionally, as I've made it known before, I'm not done having kids (or at least not done trying to have kids anyway).



The surgeon was as I expected him to be - tan, callous and emphatic over my need to have a tummy tuck. No surprises there. He said that my diastasis was of the "varsity level", in the top 25% for the worst he's seen. I think that's doctor speak for "your shit's jacked up".



I asked about having arthroscopic surgery to correct the abdominal separation but not have skin/tissue removed and he told me that a.) he doesn't do that kind of surgery, although other surgeons will and b.) that it would create curtains of hangy skin for me.



I'm not convinced that that's not an option so I'll be finding another surgeon to consult with, but that's a story for another day.



According to him I have a lot of excess skin and extremely bad stretch marks. Now, I know my stomach is pretty beat up. But really, I don't think my skin or my stretchies are that bad. In fact, I'm fine with them, I don't mind living with them. It's the poofiness and the umbillical hernia (due to the muscle separation) that I stand issue with.



As he was walking out of the consult he saw my abdominal binder and laughed - "oh, you wear a splint? You can just throw that thing out. It won't do anything for you, that is unless it makes you feel better wearing it."



So I guess I'm back to square one, or maybe it's square negative four. Cause I feel even more defeated than I did before. I know I am only 5 months postpartum, but I still look pregnant. I know that I have to give myself more time to recover, but I still look pregnant and the "professionals" keep telling me that this look is permanent. When I don't wear a binder my stomach slowly distends to the point that I have a belly similar to what I looked like around 14 weeks.



And I'm frustrated, self-conscious and sad about all of this. And those feelings have nothing to do with my children or my love for them.



So without further ado - here is my belly at 5 months postpartum. I will continue to do the exercises and wear a binder and the like, because I don't know what else to do. Regardless, I am giving myself until October (nine months in, nine months out) to see what effect plain, old-fashioned time has on my recovery.



I'm left wondering is there such a thing as a plastic surgeon that doesn't recommend surgery?

Diastasis Recti

**If you found my blog while researching diastasis, welcome! I get many of the same questions emailed to me regarding this post, so I thought I'd try to answer them here. I was 4 months postpartum when these pictures were taken. I have done physical therapy, transverse abdominal exercises, worn a splint/abdominal binder and tried the tupler technique. None of this has made a difference. My stomach greatly improved by 9 months postpartum (on its own) and even more so by 12 months postpartum. However my diastasis is unchanged. Once I am done having children I will be getting a tummy tuck to correct my hernias and diastasis and to put my body back together again.**



I start postpartum physical therapy in two weeks to help correct diastasis recti which is leftover from my pregnancy. Diastasis recti is a separation between the left and right side of the abdominal muscles that covers the front surface of the belly. A diastasis recti looks like a ridge that stretches from the bottom of the breastbone to the belly button. As your muscles relax throughout the day, the ridge gets bigger. Any strain on the muscle causes the size of the ridge to increase as well. To give you a better idea, here's what my stomach looks like.

For several weeks now, I've thought that my stomach wasn't healing quite right. But every time I mentioned it to someone I was told that I "just had twins" or that I was being too hard on myself or (and this is my favorite) I was asked if I had an eating disorder or if I was suffering from postpartum depression.



I finally said to hell with it and scheduled an appointment with my OB. And, as it turns out, I was right. My abs were so stretched from the last trimester of my pregnancy that the muscles are abnormally (i.e. more than 2 1/2 finger widths) separated. Additionally, the right side of my stomach sticks out farther than the left side, which isn't surprising considering that Reese - my right side baby - used to curl up in a ball and scoot her little heiney up under my rib cage at night.

 

{ what my stomach looks like when the muscle is relaxed }

 

{ what it looks like when I tighten my core }

Anyway, while my body will continue to heal with time, only specific core work will fix the problem. Thankfully I was able to locate a physical therapist that specializes in postpartum recovery. I'm eager to start PT. I think I could love my postpartum body (battle scars and all) if my stomach healed properly.



So that's that. I'm not entirely crazy (yet). I really hope this does the trick. I've read if core work doesn't realign the muscle that the only other option is surgical correction, which is something I'm not willing to undertake. I hate hiding under big shirts and my back is freaking killing me - something I'm sure isn't helped by scooping up the bambinos a thousand times a day.