Post Cancer Breast Reconstructions

Hello Everyone….

Back to the blogging board. This time I’m trying to write about something that every woman should know about and be aware about.

Yes, I’m talking about “Breast Cancer Awareness” and the “Pink Ribbon Run 2010” to be held this year.

Many of you must have also noticed the strange facebook satus messages which were again put out there to create awareness, regarding breast cancer.

But, what I’m going to be writing today here, is taking it a bit further. Yes, prevention is better than cure… and awareness to identify the problem early and deal with it is very important. But I deal with people who are already diagnosed and are operated on or have had their breasts removed in part or completely as a result of this disease.

I’m talking about “Rehabilitation awareness or Reconstructive awareness” as I would like to call it. Most if not all the women who have an established breast cancer are subjected to severe mental trauma for having to loose a breast – a sign of womanhood. That, many of them find more traumatic, than dealing with the actual disease - cancer.

The low awareness regarding the reconstructive options for such patients is appalling. We need to spread awareness to tell these women… this is not the end, they don’t need to feel inadequate or incomplete. There are options to reconstruct the lost part of your body and help them feel complete again.

As with anything in the world, the old adage holds true here too – “A stitch in time saves nine”. Early detection might help with getting away with only a lumpectomy rather than a full mastectomy.

So, yes early detection is the key, and for that awareness is a must. But, in cases with an established lesion, we have found that it is easier for patients’ to fight it knowing that they can be treated to get rid of the disease and it need not come at the cost of losing a part of their body leaving them “incomplete”. Of course many of them even if not reconstructed, over a period of time do reconcile to the situation, but the “quality of life” is not the same.

" Reconstruction is not an option….. in fact it must be the right of the patient. "

Every patient who undergoes a deforming surgery should be offered a reconstruction. It is her choice whether she goes ahead with it or not and this has to be discussed with them right at the outset when a treatment plan is made. Nowadays, every Oncology center has a good reconstructive team which is capable of planning and executing the same so that no patient has to go home feeling incomplete. With newer modalities of treatment and diagnosis, the reconstruction can be performed in the same sitting without the need for a secondary procedure later on.

There are many significant advantages of such an approach. The patient find it easier to deal with the trauma of deforming surgery, the quality of life is better and acceptance of curative resections will be more. There are some more advantages from the medical point of view with an immediate reconstruction which I will discuss during the course of this blog.

Now that we have established the need for reconstruction of the breast, let me just briefly highlight the various reconstructive options. For ease I will broadly classify the treatments into:

1. Variations in treatment itself
2. Reconstructive options
3. Ancillary procedures.

Variations in Treatment:

Early detection helps giving us more options from the treatment point of view as in instead of doing a radical surgery to remove the full breast, variations such as Lumpectomies, Quadrantectomies, Partial mastectomies, Nipple sparing mastectomies or skin sparing mastectomies and the likes have come in. Of course as these fall into the purview of an Oncosurgeon and it would not be prudent on my part to be commenting on them.

But, it’s just to say that now, with early detection and by combining different modalities of treatment, the need for radical surgeries can be reduced.

Reconstructive Options:

But, when there is a situation wherein a part or the whole breast needs to be removed, we come into the picture to help with reconstruction of the breast.

Breast reconstruction involves using tissues from the body to reconstruct the breast either with or without an implant.

Implant Reconstruction:

In skin sparing mastectomies, partial removals or major lumpectomies, when the skin cover is more or less intact, then a reconstruction using a Silicon implant with or without a muscle flap is done. A muscle flap is combined along with the implant if only a think skin envelop remains to give better contour and also protection to the implant.

In cases where the skin envelop is more compromised and necessitates removal, then a combination procedure is done, where in a muscle flap is rotated from the back and then a tissue expander is inserted under this muscle to create a space for an implant. After 2 months or so, once the space is adequate, a silicone implant can be inserted or alternatively fat grafting to the breast can be done.

Breast reconstruction with Muscle & Skin Flaps:-

This kind of reconstruction is done using muscle and skin from other parts of the body to reconstruct the breast, when there is skin loss as well.

When a partial mastectomy is done or the native breasts are small, we could reconstruct using a Latissimus Dorsi Myocutaneous flap which is rotated from the back into the chest to reconstruct the breast. This can be combined with an implant as well. This muscle can be harvested to reconstruct the breast without too much of a deformity to the back and without significant loss of function. But this cannot be used when larger reconstructions are required.

For larger reconstructions the flap used is called the TRAM flap. This flap has been the workhorse for breast reconstructions for many years now. The main advantage of this flap is it provides good bulk for larger reconstructions and by removing it the patient gets an added advantage of having a flat tummy. This flap uses the fat and skin from the lower part of the tummy which is rotated into the chest to reconstruct the breast. This skin is normally discarded when we do a tummy tuck. So the patient get a tummy tuck as well as breast reconstruction in the same sitting.

Now there are more modifications to this flap allowing for more significant reconstruction with better aesthetic results.

Nipple reconstruction is usually done as a secondary procedure at a later date.

Ancillary procedures:

These are procedures done after the initial reconstruction to improve the result of the reconstruction and or the aesthesis.

1. Nipple reconstruction: this is done as a secondary procedure. This is a minor procedure done to reconstruct the nipple using tissue from wither the opposite nipple or a skin graft of vulval skin.

2. Reduction of the opposite breast.: Sometimes the native breast maybe too large, in such cases the reconstructed breast will be smaller than the native opposite breast. To help give a better balance a reduction mammoplasty of the unaffected opposite breast maybe required, but is not necessary. The choice is left to the patient.

3. Scar revisions: sometimes rarely the scars can thicken or some scars may widen needing a scar revision later on.

So, from this brief write up, you can see that there are well established procedures for breast reconstruction after a mutilating procedure following cancer of the breast. But the awareness amongst patients is still low and hence patients need to understand and ask for reconstructions.

As I said before, in today’s day and age, no patient should go without a reconstruction. There are enough and more plastic surgeons in private and in government hospitals, capable of providing these reconstructions.

Hope we can spread the word around so no woman who has had to deal with a cancer of the breast be allowed to suffer the added pain of feeling incomplete after a mutilating procedure.

It is no longer a question of if one lives but also a question of how one lives – The quality of life….is point of emphasis here.

Dr.Surindher

www.cosmesisindia.com

Cosmetic Surgery in India - Understanding the Battle of the "BULGE" !

Hi everyone… back after a long break.

I have often been asked that the blog dealing with the issues it does, has not yet touched upon an issue that every one of us tries to cope with at some point in our lives. You may ask what issue that is……. It is the issue of weight management.

I know each and everyone of us (including me) at some point in our lives are fighting the “battle of the bulge”, hence I thought of putting down a few of my thoughts on the same from a personal point of view and from a health professional’s point of view.

Another reason for this delay in writing about this could be fact that notwithstanding the “magical guaranteed weight loss” adverts that I’m sure everybody has seen, this is a difficult issue deal with. Let me be a party pooper here by saying emphatically…there are no and I mean NO SHORT CUTS.

So let us see why this is such a big problem and what are some of the factors that play a role in weight gain. I would call it weight gain rather than obesity because the term obesity does not include overweight people by definition.

This brings us the fundamental question, when would one be called normal / overweight/ obese or morbidly obese? This classification is based on BMI or Body Mass Index, which is basically a product of a person’s bodyweight divided by a person’s height. A BMI of 18-25 is normal, 25-28 over weight, 28-35 obese and above 35 morbidly obese.

You can calculate your BMI using this online link below:

BMI Calculator

Why does one gain weight? This is a question the answer to which each and everyone wants to know, because if we know the answer to this, very easily we can avoid the causes thereby avoiding weight gain.

Sounds pretty simple, doesn’t it?? Sadly it isn’t that simple.

But to take a common analogy that I give to my patients’ weight gain is like a bank balance, there are only to ways to increase your bank balance (weight) either you earn more (increased intake) or spend less (decreased output).

But sadly I’m sure all of us agree it’s easier to gain weight (except for the lucky few who have genetics on their side), than increase your bank balance. Now once we have the grass root level basic fundamental cause of weight gain let us examine a few reasons as to why and how it actually happens.

I’m sure we all have read enough and more about all this in all kinds of forums and media, let me just recapitulate a few of the reasons which most of us commonly face. I’m specifically not going too much into the technical details and trying to give you the gist of things. Secondly, I’m not touching upon certain medical conditions for weight gain, which I will briefly discuss during the course of the blog entry.

INCREASED INTAKE / WRONG INTAKE / IMPROPER INTAKE

As you can see from the heading, it is not only increased intake but also the intake of wrong kinds of food and improper intake, which also contributes to weight gain.

1.Over eating: Though most of us tend not to agree to it, it is often the most common cause for weight gain. Every time you have that extra spoonful, it adds up in the long run. It is said that after a meal one should feel that he can have a little more…. that, is the time one should stop. But more often than not, we stop when we feel full and that is already too much.

2. Fast food: Fast food is fast to make and convenient to eat can be eaten on the move but more often than not is full of fats/cheese & salt.

Anyone who has read science in school knows that fat has more calories (9Kcals/gm) as compared to protein (4Kcals/gm) or carbohydrates (4Kcals/gm). So, the more fats you eat the more calories you are putting in. Carbohydrates are easy to absorb and after your basic energy requirements are met, are converted to fat for storage.

Chips – a favorite amongst most is another common cause. An old saying for them, which holds very true, is “ A minute on your lips & a lifetime on your hips”, hence avoid them.

Increased salt intake causes more water retention in the body and hence is also an important factor for weight gain.

3.Improper timing: The time of a meal also is an important factor. Food should be eaten at least 2 hours before one goes to bed to allow digestion to occur properly. So, siesta’s after a heavy lunch or eating just before going to bed are not such good ideas after all.

There is research also to suggest that, the later in the night one eats, the more chances are that all that food is being converted to fat. So, having “ a midnight snack or munchies” is again not such a great idea.

4.Alcohol: Alcohol has often been blamed for gaining weight but the gain in weight is more related to the increased snacking, which goes along with consumption of alcohol.

5.Fizzy Drinks: These are aerated drinks with empty calories, which are of no use and add up to the over all “Bank Balance of Calories”. Instead, substitute it with fresh fruits or fresh lime, which is much healthier but of course try and avoid excess salt or sugar in them.

DECREASED OUTPUT:

This is now turning out to be an important part of the whole weight gain process, especially so in youngsters and children.

1.Sedentary lifestyles: Now with the comfort levels increasing, activity has reduced. We use the lifts instead of stairs, vacuum cleaners instead of brooms, cars instead of walking, etc. The amount of calories burnt per day is decreasing with more mental activity than physical.

Some amount of physical activity is needed daily to keep the Basal metabolic rate higher so that you can burn more calories. Of course though ideal, considering family and work pressures, it is understandable that a regular gymming schedule is not always possible.

But, one can incorporate small things into the daily schedule to increase the output like taking the stairs instead of the lift, walking to the nearby store instead of driving, morning or evening walks, etc which do not take up too much of your time but help in spending those calories.

2. Children especially should have some regular physical activity in their daily schedule or we are going to be waking up to a generation of overweight youngsters. It is already happening in the west and is a major health hazard. We can see it happening around us in India too.

Real games instead of Video Games, fruits instead of chips or pizza & fruit juices instead of a fizzy drink should be the mantra for the kids.

MEDICAL CONDITIONS FOR WEIGHT GAIN:

There are a few medical conditions that can be a cause for weight gain. These are usually hormonal imbalances. The most common being:

1.Hypothyroidism: Here there is a decreased secretion of “Thyroid Hormone” which is responsible to maintain the Basal Metabolic Rate and hence there is a tendency towards weight gain. This is a treatable condition and after proper tests to find out the hormonal levels, replacement of the hormones causes a reduction in weight.

2. PCOD: Poly Cystic Ovarian Disease or PCOD is another condition associated with weight gain. Here again the hormonal imbalances cause weight gain and the weight gain in turn worsens the PCOD. Medical & surgical options are available for treatment of this condition. A curious thing seen here is that weight reduction helps with the gyneacological condition with normalization of hormones.

3. Adrenal Hormonal Imbalance: This also can cause weight gain because of water retention.

WEIGHT GAIN & DIETING

A lot has been written n said about dieting and weight loss. Every other person is an expert in some sort of a diet. But a recent study has brought the proper perspective, as I have been saying for quite some time now, its not what kind of a diet you follow but the total intake versus the total output.

So whether it’s a low carb diet, a low fat diet or an only protein diet, it doesn’t really matter. What matters is,the total amount of calories going in.

Crash Dieting is a not a way to loose weight at all. You might loose weight initially but you are loosing muscle bulk and replacing it with fat. And most of the food that one eats gets converted to fat directly because of the body’s survival mechanisms. Secondly, with crash dieting there is a tendency to alternate binging with crash dieting and this doesn’t help.

So, what one needs is a proper balanced diet according to the work he or she does, which has all the necessary nutrients.

TREATMENT OPTIONS

I’m sure all of us have heard or read quite a bit on the treatment options. I’m not going to discuss exercise, lifestyle modification and diet control which are essential to all treatments as an adjunct.

For the ease of understanding, I will divide the treatment options according to the BMI.

BMI of 25-28(30) – Overweight Category:

This is the category for which we have the most number of options.

1. Isometric Exercise/ Non Surgical Body Contouring – This is an option where in, with the help of targeted muscle stimulation & Infra red waves, isolated areas of the body are treated to achieve targeted contouring and inch loss. Here the patient comes in twice or thrice a week to the center, where the machine does the work for them and helps to achieve targeted contouring.

Very good for people in whom muscle laxity is a cause for bad body contour especially in the tummy area. Also very good immediately post pregnancy to help reduce the flab and tighten the muscles which have become loose post pregnancy and child birth

2. Ultrasonic Lipolysis: This involves breaking down the fat cells directly with the use of a non-invasive ultrasonic wave. The patient comes in once a month for the treatment, which lasts 45 mins to an hour. The released fat has to be reabsorbed and excreted by the body. It works well for small isolated areas like the saddlebags, lower tummy. This doesn’t work for large areas.

3. Injection Lipolysis or MESOTHERAPY: This involves giving multiple injections in the target areas to help dissolve fat in that area. The injection is usually of a derivative of Soya protein, which helps the cell membranes of the fat cells to break down and release the fat into the body. This is absorbed by the body and excreted.

It requires injections maybe once a month for 4 or 5 times. It works well if given properly and for small areas like the double chin or the saddlebags. Contrary to what people might claim it is not for large areas. Complications in the form or small injections abscess or collections of liquefied fat, which may require drainage, are occasionally seen.

4. LASER Lipolysis: This is a minimally invasive procedure which involves insertion of a small LASER probe in the affected area help break down the fat cells in the track of the probe thereby releasing fat into the body which is reabsorbed and excreted. This is also an office procedure and requires multiple sittings maybe a month apart.

Works well again for isolated areas like double chin, cheek fat, saddlebags, arms, etc. Large volume Lipolysis again is technically possible to a certain extent but not practical. The patient does need to use pressure garments, should have the patience to wait for the results for a few months and of course undergo multiple sittings.

5. Liposuction: This is a surgical procedure where a cannula is inserted under the skin by small 1-1.5 cm incisions in hidden areas to suck out the fat. This again is a procedure for body contouring. Though one does loose weight, he will loose more in inches

There are various techniques like the mechanical, ultrasonic, VASER, power assisted. All these are different methods of suction depending on the type of probe used to breakdown the fat cells.

As regards to the technique there is also the tumescent technique which is the preferred technique nowadays and basically involves infiltrating large volumes of saline along with some drugs to help minimize bleeding and trauma to other structures in the vicinity.

Liposuction can also be classified according to the volumes to be removed. Small, moderate or mega liposuctions. Small volume suction can be done under local anaesthesia. Moderate volumes can be done under local anaesthesia with sedation or general anaesthesia depending on the patient’s comfort level. Mega liposuctions require anaesthesia, hospitalizations and in some rare instances blood transfusions.

Internationally, the accepted volumes of fat that can be safely sucked out at one sitting is @ 8% of body weight in men and @ 9-10% of body weight in women. This is because of the fact that men tend to have an equal amount of fat inside the abdomen, whereas in women most of the fat is extra abdominal and also the fat that men have more fibrous fatty deposits. Hence, women are good candidates for liposuction.

Problems after liposuction are because of the swelling. Here as the fat is physically being sucked out, the effects are noticed immediately, but in a few days swelling sets in and takes around a month before significant changes can be felt. This also depends on the areas targeted and the amount removed. Full healing takes around 3-4 months and during this period the patient needs to wear a pressure garment to help the skin shrink. Some amount of unevenness maybe present which gradually settles with time and massages.

Rarely in smokers, there maybe areas of skin necrosis. Sometimes especially with large volume liposuctions, there maybe some collection of fluid called seroma’s which might require drainage.

BMI of 30-35 – Obese Category:

This category is the so-called “Grey Zone” of weight loss treatments. As these patients are not yet candidates for a Bariatric procedure and the procedures for the overweight category cannot fully help in treating these patients. But increasingly we are seeing patients in this category.

In these patients it has to be a combination of procedures and sometimes multiple sittings are needed to get the desired changes.

More often than not we do large volume liposuction in such cases, maybe one or two sittings with a gap of 6 months in between combined with a proper diet and exercise schedule. The procedure of Liposuction has already been discussed.

BMI of 35 and more – Morbidly obese Category:

These patients have other metabolic problems along with the fact that they are overweight. These are candidates for Bariatric procedures that are procedures aimed at reducing the intake drastically (Gastric banding or Sleeve gastrectomy) or reducing absorption of food (Gastric & Duodenal bypass procedures).

These are major surgeries and have to be done in specialized centers and involve a multidisciplinary approach with the involvement of plastic surgeon, gastroenterologist, psychiatrist, dietician, physical therapists, anesthetists, etc. This itself is a topic by itself.

The aim of this blog was to try and bring things into perspective for a person looking at weight loss or to just get in shape. Ultimately, “ a Stitch in time does save Nine”! So the earlier we wake up to the fact that weight is becoming a problem to all of us, the better it is. If not to reduce, at least try and modify our lifestyle and being about some changes in how we do things, it might help prevent the problem from becoming worse, where a much more drastic and major procedure might be required.

As you must have seen in the course of the blog that, this is not a simple topic and I have not even scraped the surface of the problem. But, the aim is to try and simplify things so one can understand what are the little things we can do to bring about a bigger change.

Whatever said and done, all the procedures are only an adjunct to lifestyle modification to get the full benefits in the long run. Change in dietary habits, maintaining a negative intake output balance, increasing physical activity will all go a long way in helping one keep fit and stay healthy.

So let us bring about the change… by being the change!!!!

So here’s to a new, fit, healthy, better looking you..!!!

Dr.Surindher

www.cosmesisindia.com

"Mummy Makeover" ... I

“A Mom Makeover!”

Sounds trendy doesn’t it???

Well not really, it’s new packaging of the procedures already being done, as we shall discover in the process of this blog and the next.

Why the mom makeover at all?

The woman being the one to create life, goes through many changes physically during the process of pregnancy, giving birth & nursing the child. In a way, it is a sacrifice she makes to create and bring forth a new life.

But, the question still remains, why the makeover at all. What are the changes that occur which need to be corrected.

Doc, I jus saw myself in the mirror today and I was shocked, as I couldn’t recognize the person I saw in the mirror. It was definitely not me..!!!

This is a common complaint women come to us with. During their pregnancy, the mother and everyone around are concentrating on the eating, weight and the unborn child’s well being. After birth it is again the child who is the center of attention, after that till the child starts going to play school, the mother is totally neglecting herself. Then one fine day when she has a little free time from kids and family, she looks at herself and cannot recognize the person in the mirror.

It is not intentional, that this happens. It’s just how things are prioritized in life. I’m not saying that we do not need to give attention to the child during that period. Just that, a little bit of attention to the mother during the pregnancy, childbirth and post birth period, will go a long way in her not having to feel that way a few years down the line.

So what exactly am I talking about here?

To simplify the understanding of what needs to be done, let me first start by enumerating and discussing few of the issues that form the basis of the problems to be corrected in a Mum Makeover.

1. The Tummy: The abdomen, especially the lower abdomen is the area which bears the most insult during pregnancy. Because of the growing womb, the skin is stretched, the muscles are stretched, and there is collection of fat because of the weight gain. Post childbirth, the skin stays loose, has lot of stretch marks, there is a prominent bulge in the lower abdomen because of the loose muscles. All these are compounded by lack of physical activity concentrated to the specific area. Also, with more women now going in for cesarean sections, the lack of activity in that area get further delayed.

2. The Hips: This area is genetically programmed to carry more fat in a woman (the pear shape). More so during pregnancy and post pregnancy. This is genetically the reserve, which the woman accumulates during pregnancy. Combined with less physical activity in the immediate post partum period, tends to get worse.

3. The Breasts: The breasts also bear equal brunt of the pregnancy and post delivery period. During pregnancy and lactation there is development of the milk glands to produce milk for the newborn and hence as they develop they replace the fat that is present in the breast. Once the period of breast-feeding is over, the glands get back to their pre pregnancy state, but the lost fat doesn’t come back and that is the reason for the breast looking empty and sagging. Also because of the stretch marks on the skin of the breast, the skin doesn’t shrink back to the reduced volume giving it the appearance.

4. The Vagina: Post childbirth, the vaginal canal is stretched and like any muscle that is stretched a lot, it needs toning to bring it back to its normal size and tone. In fact in the west this has been used as a punch line to ask people to go in for caesarean sections… “ Have your child the C sec way and keep your passage the honeymoon way”. But that is not required, the vaginal passage was physiologically meant to stretch and contract. But a few things have to be kept in mind, as we will discuss later on in this blog.

5. The Face: Post pregnancy and childbirth many women tend to have pigmented patches on their faces called “ Melasma” which just persists even after childbirth. This occurs due to hormonal changes during pregnancy. Also some patients might have a double chin or a more rounded face as part of the generalized weight gain seen during this period.

Now that we know what are the few changes, which occur during the period starting from getting pregnant to one realizing that their whole body image has changed, is there something we can do to reduce these insults if not prevent them altogether?

The good news is YES…!!! There are things, which one can do during pregnancy and in the immediate period following childbirth to help prevent or at least reduce the changes that are occurring in the body.

Pregnancy Care:

The whole aim of the “pregnancy care” concept is to help the mother to be to take care of her body by doing small things to prevent future problems. The main problem during pregnancy is the weight gain and the increasing abdominal girth. When this rapid weight and circumference gain is more than what a person’s skin can tolerate, the dermis which is the supporting layer of the skin ruptures leading to stretch marks. So to prevent stretch marks the best thing that one can do it just spend 10 minutes each in the morning and night out of 24 hours to do a little something to help keep the skin supple to prevent stretch marks. The areas to be concentrated on are the abdomen (more so the lower abdomen), the breasts, the buttocks and the thighs.

The best way to keep the skin supple is to moisturize it. It could be with the help of oils or body lotions. Just take 10 minutes out of your daily schedule to gently massage the areas with a body oil or body lotion. This when done over the period of the pregnancy will make the skin supple and allow it to stretch easily as the mother gains weight and the abdomen gains circumference. This is true for the breast as well as other areas as mentioned before.

This simple step can prevent a lot of the problems later on. Also the second trimester is the most important period to do this because in the last trimester the weight gain and the circumference gain is very rapid and doing it then will not give the skin sufficient time to become soft and supple enough to stretch.

Post Child Birth:

Post delivery the single most important thing a mother can do to help her regain her figure and push her tummy back is the same thing that our grand mothers used to advice. That is the use of a binder or as the grand mothers would advice tying a sari around the abdomen tightly.

This helps in two ways, firstly it is pushing the skin back to its normal position and allowing it to shrink as it normally should and secondly it is also pulling the muscles together to the normal position they should be in. Hence, this when done properly for the next few months will greatly help in one getting back to the pre pregnancy state. Of course if the stretch marks are too bad then the shrinkage might not be to the extent that is desired for, as the skin is like a rubber band broken at multiple places, but even then the muscle toning itself is enough reason for one to use the binder.

This can be done for patients who have undergone C-Sec’s too. After the initial week or two of the healing time for the wound, the binder will help as mentioned above.

The other things that the mother can do are to continue the oil massages to the body and to get into some sort of regular physical activity. Be it morning walks or evening walks or treadmill, etc. I know there would be lot of women shaking their heads n saying… “ What does he know.. He’s not a woman! How do we find time for it? ” But for that, ladies.. let me just say one thing… “Its not easy agreed but if you do it.. it will benefit you. You are preventing a surgical procedure and getting back to how you were and not letting things get out of hand…!” So you work out the math!

As far as the vagina goes, the easiest way to help tone the pelvic musculature to get back to what it was is to do some basic exercises called Kegel's Exercises. The aim of these exercises is to strengthen and fortify the muscle tone of the muscles of the pelvic floor which in turn. It basically involves contracting your pelvic muscles and keeping them contracted for a period of time and doing this in cycles all through the day. The best part of this exercise is that it can be done anywhere and anytime and doesn’t need any equipment.

So now that we know what are the few things one can do to prevent things from getting out of hand and one finally landing up in the so called “ Clutches” of the “Cosmetic Surgeon”, I hope more and more to be mothers will take better care of themselves to prevent or reduce these problems.

As, I will be dealing with the specific surgical management of these problems and the actual “Mummy Makeover”, I think this blog should have been titled…” Tips to prevent a Mom Makeover”.

Happy reading…

Dr.Surindher