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9 Establishing aPost-maternity Strategy
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56. Seruya M, Baker SB. MOC-PS(SM) CME article:
venous thromboembolism prophylaxis in plastic surgery patients. Plast Reconstr Surg. 2008;122:1–9.
57. Guyatt GH, et al. Approach to outcome measurement in the prevention of thrombosis in surgical
and medical patients: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College
of Chest Physicians Evidence-Based Clinical Practice
Guidelines. Chest. 2012;141:e185S–94S.
58. Gould MK, etal. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and
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59. Pannucci CJ, etal. Benets and risks of prophylaxis
for deep venous thrombosis and pulmonary embolus
in plastic surgery: a systematic review and metaanalysis of controlled trials and consensus conference. Plast Reconstr Surg. 2016;137:709–30.
60. Swanson E.Personal communication. 2014.
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LM. How safe is thromboprophylaxis in abdominoplasty? Plast Reconstr Surg. 2012;130:851e–7e.
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and increased risk?” and “papers regarding operative
times and complications can be misleading”. Aesthet
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75. Chasan PE, Marin VP. Papers regarding operative
times and complications can be misleading. Aesthet
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complications after plastic surgery: a multivariate
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85. Editorial. Team work in organization. Wall Street J.
1903.
Combining Plastic Surgery
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withVaginal Delivery or C-Section
GuillermoRamos-Gallardo, DanielaLeón-López,
JesúsCuenca-Pardo, ArlinePaolaArroyo-Fonseca,
andRunoIribarren-Moreno
10
10.1 Introduction
The most frequent plastic surgeries combined
with obstetrical procedures are abdominoplasty
and liposuction. Considering the studies done in
our population and medical evidence, we cannot
recommend to combine this procedure during the
obstetrical procedure. Maternity death is a serious problem and consequence found in this kind
of procedures as well important number of complication as seroma, necrosis and unsatisfactory
results that cannot make a recommendation to
consider this kind of combination.
10.2 Scientic Evidence
The current interest in having a youthful gure
and for proper nutrition and exercise has an inuence on all women; sometimes, it can be considered that pregnant women can have a plastic
surgery during delivery to regain as soon as possible the gure that was in the past or desired.
G. Ramos-Gallardo (*)
Asociación Mexicana de Cirugía Plástica, Estética y
Reconstructiva, Mexico City, Mexico
Centro Universitario de la Costa, Universidad de
Guadalajara, Guadalajara, Mexico
D. León-López · J. Cuenca-Pardo ·
A. P. Arroyo- Fonseca · R. Iribarren-Moreno
Asociación Mexicana de Cirugía Plástica, Estética y
Reconstructiva, Mexico City, Mexico
The famous “mommy makeover” that transforms both the abdomen and the breasts (since
they are the two regions with the most visible
changes in the postpartum) leads many women to
request for a tummy tuck; the conict arises when
that request is done at the same time of cesarean
section or natural birth. Then the question arises:
Is it safe to perform a tummy tuck in the immediate postpartum period?
The proposal to reduce surgical time with both
procedures comes as a possibility. Although the
normal physiological and hormonal changes are
present, some surgeons may consider this procedure as possible. We decided to analyze the evidence in our population: rst to know if plastic
surgeons have experiences with this procedure
and second to know the results with this type of
combination.
A survey is a way of obtaining relevant data
by asking questions to understand the issue, create a hypothesis, and develop solutions and
recommendations.
We executed a survey, validated in content and
consensus, and sent it to the members of the
Mexican Association of Plastic Surgery in the
months of May and June 2016.
We found that 61 surgeons performed a combination of abdominoplasty and cesarean section
or natural delivery. The total number of procedures reported was 808, with an average of 13.24
procedures per surgeon, varying between 1 and
41 procedures per surgeon [1].
© Springer Nature Switzerland AG 2023
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G. Ramos-Gallardo et al.
The plastic surgery procedures were as follows: abdominoplasty (242 cases, 29.95%),
abdominoplasty plus liposuction (210 cases,
25.99%), mini-lipectomy (18 cases, 2.22%),
mini-lipectomy plus liposuction (121 cases,
14.97%), and liposuction (217 cases, 26.85%). In
783 cases (96.9%), the combination was with
cesarean section and in 25 cases (3.13%) with
vaginal delivery (Table10.1).
The following complications occurred, in
order of prevalence: seroma (255 cases, 31.57%),
thrombosis (212 cases, 26.23%), infection (170
cases, 21.03%), skin necrosis (127 cases,
15.71%), and hematoma (42 cases, 5.19%).
There were three deaths due to thrombosis
(0.4%). There were redundant skin abdominal
wall defects in 336 cases (41.66%), unaesthetic
scars in 291 cases (36.11%), abdominal wall
defects in 134 cases (16.58%), unpleasant contours in 22 cases (2.72%), and rotational folds in
22 cases (2.72%) (Table10.2).
Fifty-ve surgeons (90.16%) decided to stop
delivering with these practices.
Table 10.1 Types of procedures
Type of aesthetic procedure
Abdominoplasty 242 (29.95%)
Abdominoplasty plus liposuction 210 (25.99%)
Mini-lipectomy 18 (2.22%)
Mini-lipectomy plus liposuction 121 (14.97%)
Liposuction 217 (26.85%)
Type of obstetric procedure
C-section 783 (96.9%)
Vaginal delivery 25 (3.13%)
Table 10.2
Seroma 255 (31.57%)
Thrombosis 212 (26.23%)
Infection 170 (21.031%)
Skin necrosis 127 (15.71%)
Hematoma 42 (5.19%)
Abdominal wall redundancy 336 (41.66%)
Unaesthetic scars 291 (36.11%)
Abdominal wall defects 134 (36.11%)
Unpleasant contour 22 (2.72%)
Rotational folds 22 (2.72%)
Mortality 3 (0.4%)
Types of complications
During pregnancy, women go through physiological changes in all of their organs and functions; breathing changes occur starting at the
fourth week of gestation, and edema may occur
in the upper respiratory tract, which favors infectious processes. The mucous epithelium becomes
friable and can be easily damaged when placing
an orotracheal tube for general anesthesia [2].
Additionally, a pregnant uterus elevates the diaphragm and the heart and can lead to changes in
the electrocardiogram, arrhythmias, and functional murmurs. In extreme situations, it can also
lead to pericardial effusion: circulatory volume
increases from 30 to 50% with a dilution of
hemoglobin to supply for the metabolic processes
of the fetus and to compensate for the blood lost
during delivery [3]. Progesterone induces
changes in the digestive tract; increases salivation; changes the pH in the oral cavity; increases
cavity formation, pyrosis, and gastric acids; and
stimulates the formation of gallstones and cholecystitis. Changes in the position and function of
the stomach and esophagus are present, which
leads to regurgitation and increases the risk of
bronchial aspiration. Fibrinogen and factors VII,
VIII, X, and XII prevent hemorrhage during
delivery but can simultaneously increase the risk
of thrombosis [4, 5].
Not only cardiovascular or respiratory system
changes, but also in the kidney, renal blood ow
and glomerular ltration rate rise 50–60%, creatinine clearance rises, and colloid osmotic pressure
decreases. In the skin, the patient may experience
increased extracellular uid and hyperpigmentation of the face, neck, areolas, abdominal midline, and perineum, which greatly increases the
laxity of the skin that occasionally causes stretch
marks [2].
It is important to note that all these changes
return to normal in several weeks [6].
The knowledge of the physiological changes
related to the obstetric patient is an element of
great value to make decisions when combining
procedures with a normal delivery or cesarean
section.
Before our report, we found that Ali and
Essam compared two groups of patients: one
group of 50 females that underwent both abdomi-
10 Combining Plastic Surgery withVaginal Delivery or C-Section
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175
noplasty and cesarean section and another group
of 80 women who underwent only abdominoplasty [7]. Among the rst group, 36% had complications, and in the second group, 11.3% of the
patients had complications. Abdominoplasty is
an aesthetic procedure with the highest incidence
of complications, which increases when combined with other procedures [8, 9]. The incidence
of complications that we found was 11.75%, and
it increased when combined with other
surgeries.
Benn and Spera allude to the physiological
changes that occur during pregnancy and right
after postpartum; these changes include physiological anemia, hypercoagulability, and loss of
blood during the postpartum period [10]. Patients
with these changes are not ideal candidates to
undergo combined procedures.
Matarasso and Smith indicate that the best
time to realize a body-contouring procedure is
when the patient has returned to her normal physiological status, which is reached around the
sixth week after delivery [6]. Jackson mentions
that the risk for thrombosis increases 21.5–84
times postpartum and then decreases rapidly [3].
In hospitalized and surgical patients, symptomatic thrombosis is present in 1.4–1.8% of patients
and mortal thrombosis is present in 0.8% [5, 11].
The most signicant cause of death in patients
who undergo combined abdominoplasty or liposuction is pulmonary thromboembolism [12, 13].
When both procedures are combined, the risk is
higher [8, 9]. We found a high incidence of
thrombosis (26.31%) in patients with combined
procedures. Other authors found that the combination of abdominoplasty with cesarean section
or natural delivery leads to a high incidence of
postsurgery complications and poor aesthetic
results [14]. Surgeons that were part of this
research reported cutaneous redundancy, unaesthetic scars, defects of the abdominal wall, and an
unpleasant contour.
For some surgeons, the increase in uterus volume and the secondary effects of a cesarean section caused skin accidity with crease formation
and a loose abdominal wall. These are the most
common reasons to proceed with both an abdominoplasty and a cesarean section; additionally, the
authors consider this to avoid a new surgery
meaning another anesthetic procedure. Usually,
during the immediate postpartum period, it is
common to observe persistent abdominal bulges,
lack of a dened waistline, and redundant skin in
the lower abdomen; these body disturbances are
due to the persistent uterus growth that stretches
the abdominal skin and hinders the surgeon’s
ability to estimate the adequate cutaneous resection. A few months later, the uterus involutes, the
skin loosens out, and the abdominal accidity
becomes more obvious. Infections, wound dehiscence, and necrosis are frequent complications
that are usually attributed to contamination of
vaginal exudates and disturbances in abdominal
tissue irrigation [3, 15]. Time in the operating
room should also be considered a risk factor for
complications. Combining obstetrical procedures
with plastic surgery results in a longer time in the
operating room. The obstetrical procedure is not
free of complications, as we have mentioned. If
combined with other procedures, such as any
plastic surgery, there are greater possibilities of
risk due to a longer procedure time.
We should not forget that there is a strong
association between pathological scars and pregnancy. If patients have a predisposition to this
type of condition, there is a greater chance of
having an unsatisfactory result. In addition,
patients with keloid or hypertrophic scars can
have a recurrence of these problems [16].
10.3 Home Points andConclusion
Therefore, due to the current evidence and as
long as no additional information suggests a different approach for this clinical situation, we
rmly recommend avoiding the combination of
obstetrical procedures with abdominoplasty or
any other corporal contour surgery.
Legislation in every country is different. In
our case, authority considers maternal death during the rst year after delivery. Risk must be balanced with assistance of the patient with care of
baby, and it is suggested to wait for 6months to
recover and evaluate the nal size of the abdomen and uterus.
176
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G. Ramos-Gallardo et al.
References
1. Iribarren-Moreno R, Cuenca-Pardo J, Ramos- Gallardo
G.Is plastic surgery combined with obstetrical procedures safe? Aesthet Plast Surg. 2019;43(5):1396–9.
2. Ojeda-González JJ, Rodríguez-Álvarez M,
Estepa-Pérez JL, Piña-Loyola CA, Cabeza-Poblet
BL. Cambios siológicos durante el embarazo.
Su importancia para el anestesiólogo. Medisur.
2011;9(5):15–25.
3. Jackson E, Curtis KM, Gafeld ME. Risk of
venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol.
2011;117(3):691–703.
4. Grazer FM, Jong RH. Fatal outcomes from liposuction. Census survey of cosmetic surgeons. Plast
Reconstr Surg. 2000;105:436–46.
5. Bates SM, Greer IA, Middeldorp S, et al. VTE,
thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines. Chest. 2012;141:e691S–736S.
6. Matarasso A, Smith DM, Darren M. Strategies for
aesthetic reshaping of the postpartum patient. Plast
Reconstr Surg. 2015;136:245.
7. Eli A, Essam A. Abdominoplasty combined with
Cesarean delivery: evaluation of the practice.
Aesthetic Plast Surg. 2011;35(1):80–6.
8. Winocour J, Gupta V, Ramírez JR, Shack RB, Grotting
JC, Higdon KK. Abdominoplasty: risk factor, complications rates, and safety of combined procedures.
Plast Reconstr Surg. 2015;136:597e–606e.
9. Hester TR Jr, Baird W, Bostwick J, Nahai F, Cukic
J.Abdominoplasty combined with other major surgical procedures: safe or sorry? Plast Reconstr Surg.
1989;83(6):997–1004.
10. Benn TE, Spera CE.Abdominoplasty combined with
cesarean section: discussion of the evidence. Am J
Cosmetic Surg. 2014;31(4):260–3.
11. Cabrera-Rayo A, Nellen-Hummel H.Epidemiología
de la enfermedad tromboembólica venosa. Gac Méd
Méx. 2007;143(Suppl 1):3–5.
12. Zaragoza-Delgadillo JC, Sauri-Arce JCA, OchoaCarrillo FJ, Fuentes-del-Toro F. Prevención de la
enfermedad tromboembólica venosa en cirugía. Gac
Méd Méx. 2007;143(Suppl 1):35–9.
13. Rao RB, Ely SF, Hoffman RS.Deaths related to liposuction. N Engl J Med. 1999;340(19):1471–5.
14. Emily J, Curtis KM, Gafeld ME. Risk of
venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol.
2011;117(3):691–703.
15. Saad AN, Parina R, Chang D, Gosman AA.Risk of
adverse outcomes when plastic surgery procedures are
combined. Plast Reconstr Surg. 2014;134(6):1415–22.
16. Park TH, Chang CH.Keloid recurrence in pregnancy.
Aesthet Plast Surg. 2012;65(5):1271–2.
Part IV
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Skin
Dermatological Changes During
https://t.me/medicina_free
andAfter Pregnancy
AnaMª.González-Pérez, DanielBancalari-Díaz,
andJavierCañueto
11
Take-Home Points
• The endocrine, metabolic, and immunological
changes occurring during pregnancy are associated with many alterations of the skin and its
appendages that are generally considered
physiological.
• Hyperpigmentation is the most common skin
alteration during pregnancy and generally
affects previously pigmented areas such as the
areola, the axilla, or the genitals. It usually
improves during puerperium.
• Although nevi tend to become hyperpigmented and increase their size symmetrically
during pregnancy, there is no evidence of an
increased risk of malignancy development. No
clinical or histopathological atypical condition of the skin may be attributed to
pregnancy.
A. Mª. González-Pérez
Department of Dermatology, Complejo Asistencial
Universitario de Salamanca, Salamanca, Spain
D. Bancalari-Díaz
Department of Dermatology, Hospital las Higueras,
Talcahuano, Chile
J. Cañueto (*)
Department of Dermatology, Complejo Asistencial
Universitario de Salamanca, Salamanca, Spain
Instituto Biosanitario de Salamanca-IBSAL, Hospital
Virgen de la Vega, Salamanca, Spain
Faculty of Medicine, University of Salamanca,
Salamanca, Spain
• Pruritus is one of the most common symptoms
during pregnancy (up to 20%) as well as the
main symptom of the four dermatoses associated with pregnancy.
• A pregnant woman with intense pruritus and
skin lesions requires a complete clinicalpathological assessment in order to correctly
diagnose a dermatosis with potential associated maternofetal risks such as intrahepatic
cholestasis of pregnancy or pustular psoriasis
of pregnancy.
• Atopic eruption of pregnancy is the most common pruritic disorder during pregnancy, and it
generally appears before any other specic
dermatosis of pregnancy. It has no associated
maternal or fetal risks.
11.1 Introduction
The skin is the largest organ of the body. It performs many vital functions, including protection
against external agents, thermoregulation, evaporation control, and sensory functions. It is composed of three layers (Fig.11.1):
• The epidermis is the outermost layer which
serves as a protective barrier. Its main component is cells known as keratinocytes, which
synthesize keratin.
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_11
179
180
Arrector pili muscle
Adipose tisue
(subcutaneous tissue)
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A. Mª. González-Pérez et al.
Hair shaft
Sweat pore
Fig. 11.1 Anatomy of the skin
• The dermis is the middle layer and is made up
• The hypodermis or subcutaneous tissue con-
required for the reproductive organs to return to
the state before pregnancy. It usually lasts 6weeks
[1, 2]. The endocrine, metabolic, and immunological changes that take place during pregnancy
are associated with many alterations of the skin
and its appendages [3, 4]. These changes are generally considered physiological, in view of their
high prevalence [5]. Many of these alterations
resolve during puerperium, but others can extend
beyond childbirth or are exclusive to the postpartum period [6, 7]. In this context, we can establish
three categories into which dermatosis may be
classied during pregnancy and puerperium:
• Preexisting dermatoses affected by pregnancy
• Specic dermatoses of pregnancy
Sweat duct
Sebaceous gland
Papilla of hair
Sensory nerve
Sweat gland
Blood vessels
of collagen. It contains hair follicles and sweat
glands.
tains fat cells (lipocytes).
Puerperium is the period after childbirth
Epidermis
Dermis
Hypodermis
• Dermatoses that are actually physiological
changes caused by pregnancy and largely induced
by hormonal and immunological alterations
11.2 Preexisting Dermatoses
Pearls and Pitfalls
During pregnancy, diseases associated with a Th1
immune response like psoriasis tend to improve,
while those associated with a Th2 response like
atopic dermatitis generally worsen.
Pregnancy may have positive or negative
effects on the state of some preexisting skin conditions. Diseases associated with a predominantly Th1 immune response tend to improve
during pregnancy, while those associated with a
Th2 response generally worsen [8].
Psoriasis usually improves during preg-
nancy and flares up 6–12 weeks after childbirth [9], whereas psoriatic arthritis tends to
become worse. Atopic dermatitis, lupus ery-
11 Dermatological Changes During andAfter Pregnancy
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181
thematosus, and pemphigus vulgaris tend to
worsen during pregnancy and improve after
labor [9, 10].
11.3 Pregnancy-Specic
Dermatoses
Dermatoses of pregnancy are a heterogeneous
group of inammatory and pruritic dermatoses
that appear exclusively during pregnancy and the
immediate postpartum period [7, 10].
Holmes and Black
(1983) Shornick (1998)
Prurigo of pregnancy
Herpes gestationis
(pemphigoid
gestationis)
Polymorphic eruption
of pregnancy
Pruritic folliculitis of
pregnancy
For many years, pregnancy-specic dermatoses were a diffuse group of overlapping conditions mostly known from sporadic cases and
series of clinical cases. The rst classication,
which distinguished four conditions, was made
by Holmes and Black in 1983 [11]. The second
was proposed by Shornick in 1998 [12], which
added intrahepatic cholestasis of pregnancy to
the previous list [13]. The most recent classication, proposed by Ambros-Rudolph etal. (2006)
[14], introduces a further entity, known as atopic
eruption of pregnancy [10, 13]. Therefore, ve
categories of dermatosis of pregnancy are currently recognized [9, 10]:
• Pemphigoid gestationis
• Polymorphic eruption of pregnancy
• Atopic eruption of pregnancy
• Intrahepatic cholestasis of pregnancy
• Pustular psoriasis of pregnancy (formerly
known as impetigo herpetiformis, but now
considered a variant of pustular psoriasis that
is probably related to relative hypocalcemia of
pregnancy)
Herpes gestationis
Pruritic urticarial papules
and plaques of pregnancy
(PUPPP)
Cholestasis of pregnancy
Prurigo of pregnancy
11.3.1 Atopic Eruption ofPregnancy
(AEP)
• Synonyms: Prurigo of pregnancy, prurigo ges-
tationis, early-onset prurigo of pregnancy,
pruritic folliculitis of pregnancy, linear IgM
dermatosis of pregnancy, eczema of
pregnancy
Pearls and Pitfalls
AEP is the most common and the one with an earlier onset of all pregnancy-specic dermatoses.
Up to 80% cases do not have a previous history of
atopy. Diagnosis is eminently clinical; no further
studies are needed unless diagnostic doubts arise.
Treatment is based on topical corticoids, emollients, and humectants associated or not with systemic antihistamines. Although it is not associated
with an increase in maternofetal risk, recurrences
are common in subsequent pregnancies.
AEP is the most common pruritic disorder
during pregnancy, occurring in approximately
50% of cases of dermatosis of pregnancy [9, 15],
and it generally appears before any other specic
dermatosis of pregnancy (around 75% before the
third trimester; generally, in the rst or second
trimester) [16].
11.3.1.1 Signs
AEP is described as a are-up or as the rst episode of skin changes with eczema and/or papules
during pregnancy in patients with atopic diathesis
in which other specic dermatoses have been
ruled out [10, 17]. The association with atopy
goes unnoticed in many patients because most of
them (up to 80%) were previously unaware that
they had atopic skin [17]. It sometimes may
appear as pruritic folliculitis (perifollicular papulopustular eruption, also known as pruritic folliculitis of pregnancy) [18].
Two-thirds of patients present eczematous
lesions that generally affect typical regions of
atopic dermatitis such as the face, neck, and
exor surfaces of extremities (Fig. 11.2
). One-
third of patients present a papular eruption on the
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d
c
Fig. 11.2 Diffuse generalized eczema lesions in a pregnant patient with atopic eruption of pregnancy (images a–c).
The skin appears dry and lichenied, especially in exural areas like the crease of the elbow (image d)
torso and extremities, with prurigo-like lesions or
small erythematous papules [10]. Xerosis is a
common occurrence.
11.3.1.2 Complementary Tests
The histology of this condition is unspecic, and
direct immunouorescence is negative. Serum
IgE is elevated in up to 70% of cases [9].
11.3.1.3 Prognosis
No risk to the mother or fetus. Common recurrence in subsequent pregnancies [15].
11.3.1.4 Treatment
Treatment is based on topical corticoids, associated or not with systemic antihistamines [5].
Emollients and humectants are also useful (topical 10% urea, polidocanol, pramocaine, and
menthol are safe during pregnancy) [10]. UVB
radiation is very useful in severe cases.
Secondary bacterial infection may require systemic antibiotics.
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