After babies if you still look pregnant 24/7, what do you need to do?
Do you need a CT scan? A general surgeon to repair? A plastic surgeon? How to repair it? How tough is it? Component separation?
Patient story:
I met a patient recently who came to me with what I affectionately call a blow out- after babies her belly stayed big and she looks 6 months pregnant every day. This is frequently associated with a hernia in the belly button and a wide diastasis. If this happens to you, you are a GREAT candidate for a tummy tuck. Not only will it look better, it will help you functionally with urinary incontinence, low back pain, bowel habits, and core strength.
This patient had seen multiple general surgeons and gotten a CT scan. One of the general surgeons said her case was very difficult and would need “component separation to fix the diastasis”. I was perplexed as to why this would be said, as component separation is a big surgery used when people have out of the norm abdominal separation issues, and she looked like a garden variety blow out from pregnancy. Please hear me- I am NOT minimizing this isn’t a big surgery, but when I do tummy tucks after pregnancy, I see a range of “damage” from the babies. The fix is a tummy tuck, with diastasis repair, and fixing an umbilical hernia is frequently associated. She looked normal to me, not needing of component separation. I was taught component separation in my plastic surgical training at Stanford, but I have used it zero times in my 25 year private practice as a plastic surgeon doing hundreds of abdominoplasties. So what is the story?
I talked with one of my general surgery colleagues to see why CT scans and a component separation would have been recommended to this patient. He said some doctors are recommending this more extensive surgery to increase reimbursement and due to encouragement from robotics companies.
NY Times article:
He recommended I read a NYT article published last year, “How a Lucrative Surgery Took Off Online and Disfigured Patients.”
The article was well written and researched. Component separation involves separating the abdominal muscles on your sides into layers to allow them to advance centrally. This weakens your lateral abdominal wall. It is a tricky surgery to do open (not even thinking about how tricky it would be laparoscopically with a robot!). We in plastic surgery used it only for the most difficult cases to get closure. The article highlighted:
- Component separation pays much more than a simple hernia repair.
- Robot companies have encouraged component separation to use their robots.
- A recent study by the Cleveland Clinic showed a 26% issue with a NEW bulge developing if component separation was done.
- It is being recommended to patients who would be better served by a traditional hernia repair.
- Many surgeons are doing it after a weekend course or online tutorials, and the article mentions many of them are releasing and cutting the wrong muscles.
Quotes from the NYT article:
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“One of the doctors she saw later, a leading hernia expert at the Cleveland Clinic, doubted that Ms. Hudson had even needed the surgery. The operation, known as a component separation, is recommended only for large or complex hernias that are tough to close. Ms. Hudson’s original tear, which was about two inches, could have been patched with stitches and mesh, the surgeon believed.
Component separation is a technically difficult and risky procedure. Yet more and more surgeons have embraced it since 2006, when the approach — which had long been used in plastic surgery — was adapted for hernias. Over the next 15 years, the number of times that doctors billed Medicare for a hernia component separation increased more than tenfold, to around 8,000 per year.”
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“Seven years ago, Sandy Aken said, she had a hernia the size of her fist. A surgeon in Huntington Beach, Calif., performed a component separation. Three months later, her belly was still protruding, and she felt like her guts were spilling out. She saw another doctor for help.
This patient has a significantly compromised abdominal wall with damaged muscle due to the history of component separation,” that doctor wrote in a summary of the visit. Another hernia surgeon told her he could not fix the bulge, she said.
Ms. Aken, 64, now looks nine months pregnant. She cannot bend over without pain, a limitation that forced her to leave her job as a caregiver.”
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What do I think?
This is heartbreaking. New techniques, fancy techniques, robots and lasers are not always better. Hernia and diastasis repairs are old school, simple, and they work. I only use mesh when needed, and for abdomens after babies, even using mesh is rare.
I am grateful to this patient for bringing this new trend to light for me- I didn’t know general surgeons were recommending component separation for straightforward repairs. And yes, I believe a blow out is a straightforward tummy tuck. I have not had a patient I couldn’t repair with a diastasis repair.
I am grateful to my general surgery colleague who discussed this trend with me. There are great general surgeons out there, and I am honored to know and work with him.
Component separation can weaken the lateral abdominal wall. It can mess up anatomy that didn’t need to be altered, and when these patients then go to a surgeon to “fix it,” they can’t. You cannot undo a component separation and put it back like it was.
Take home message for women out there:
if your abdomen was hurt from pregnancies, especially if you are blown out, fix it. But do so in a traditional fashion with an old fashioned tummy tuck. They work.
The NYT article is well written and I highly recommend reading it.
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