Mommy Makeover in São Paulo, Brazil

I recommend the Mommy Makeover for:

• women who have completed their family and do not plan to become pregnant again;

• with breast ptosis or volume loss, abdominal laxity with or without diastasis, and resistant fat deposits;

• with weight stable for at least 6 months;

• who stopped breastfeeding 3 to 6 months earlier;

• in good general health, with a complete cardiology evaluation and the clinical fitness for a medium- to large-scale surgery.

I do not recommend — or I postpone — when:

• there are plans for another pregnancy: pregnancy undoes the abdominal wall result;

• the patient is still breastfeeding;

• in my practice, BMI is above approximately 30 to 32: surgical risk tends to increase and the result can become less predictable — in that case, I generally advise losing weight first and reassess; this cutoff is not universal and depends on the overall clinical picture;

• weight has fluctuated significantly over the past 6 months;

• the patient smokes and does not plan to quit;

• the desired combination does not fit safely into two reasonable surgical stages: in that case, the answer is to prioritize and sequence, not to force it.

I assess the three components separately, and only then put together the overall plan. In the abdomen: how much skin is redundant above and below the navel, whether there is diastasis and how wide, whether there is an associated umbilical hernia, the condition of the skin (stretch marks, quality), and how much fat is present in the flanks. For the diastasis exam, I ask the patient to contract the abdomen while lying down and palpate the distance between the recti. In the breast: the position of the nipple-areola complex relative to the inframammary fold, current volume, skin quality, and symmetry — this determines whether it is an isolated mastopexy, a mastopexy with an implant, or a reduction. In liposuction: which areas, and above all how much — because liposuction combined with abdominoplasty has a limit that protects the flap's circulation.

What makes me change the plan: a wide diastasis with a hernia changes the wall strategy; a high BMI changes the order (lose weight first); a breast that needs a large implant combined with an extensive abdominoplasty may not fit within a safe operating time — and then the decision is to split it, not to compress it.

Patients with an inter-rectus distance above 20 mm meet the definition of diastasis used by the European Hernia Society, but the isolated measurement does not explain the entire function of the abdominal wall. There can also be widening and laxity of the linea alba and of the fascial tissues that integrate the recti, transversus, and obliques. Exercise can strengthen the musculature and change the distance measured in certain positions or maneuvers, but it does not recreate widened fascial tissue. When surgery is indicated, plication brings the recti together and reinforces the midline with sutures, with tension planned according to the anatomy, without confusing structural correction with simple muscle contraction.

There is no standard Mommy Makeover. There is Maria's, Ana's, Cláudia's.

I perform the Mommy Makeover under general anesthesia at Hospital Albert Einstein. Planning starts with the overall time and scale. I keep the initial surgical plan within a safe operating time, weighing complexity, the number of areas, the combination of procedures, the technologies used, the patient's clinical condition, and cumulative surgical trauma — a safety practice I adopted long before it became a regulatory requirement in São Paulo.

In practice, this means I plan the combination to fit within a safe operating time. When it does not fit — usually when a breast implant is combined with an extensive abdominoplasty and liposuction of several areas — I split it into two stages, with the interval defined at the consultation. The patient knows this before deciding, and the written plan states what is included in each stage.

The sequence within the surgery follows a safety logic:

In my practice, we begin with the planned liposuction, move on to the breast surgery indicated for each case, and then proceed to the abdominal treatment, whether lipoabdominoplasty or mini-abdominoplasty. In abdominoplasties, I routinely use Blake drains combined with Baroudi tacking sutures. Drainless techniques exist, especially using progressive tension sutures, and the literature shows they can achieve good results; my choice is to keep both strategies — tacking and drainage — as part of my protocol. The drain does not prevent a hematoma from forming and does not replace the need for re-exploration when there is significant or expanding bleeding. It does, however, allow me to track the output and can offer an early sign of bleeding, prompting immediate reassessment and the appropriate measures based on the clinical picture. For venous thromboembolism prevention, I follow the institutional protocol of Hospital Israelita Albert Einstein and perform individual risk stratification. I use mechanical measures, such as intermittent pneumatic compression and early ambulation, and add pharmacological prophylaxis when indicated by individual risk, scale, and procedure duration, always weighing the bleeding risk as well.

Each component is performed as I describe on the abdominoplasty and liposuction pages; for the breast, the technique (mastopexy, with or without an implant, or reduction) is determined by the exam.

Combined surgery carries the risks of each component plus a risk of its own: time.

• Venous thrombosis and pulmonary embolism — the most significant risk of combined surgeries. I manage it with compression stockings, intermittent pneumatic compression during surgery, early ambulation the following day and, when indicated by individual risk, pharmacological prophylaxis. The limit on planning is not due to a single risk: operating time, cumulative trauma, hypothermia, bleeding, thromboembolism, and anesthetic complexity are all weighed together.

• Seroma — fluid buildup under the abdominal flap; the most frequent complication of abdominoplasty.

• Hematoma — in the breast or the abdomen; drained when relevant.

• Abdominal flap compromise or necrosis — a risk that rises with smoking and with excessive liposuction over the flap; this is the reason for the volume limit on the associated liposuction.

• Sensory changes in the lower abdomen and areola — common and, in most cases, temporary.

• Widened or hypertrophic scarring — scar care starting in the third week; revision, when needed, after maturation.

• Infection — rare, with prophylactic antibiotics and a hospital setting.