Mr Taimur Shoaib details the options available to treat women’s aesthetic concerns following childbirth
Pregnancy is a physiological process, resulting in changes to a woman’s body during and after the pregnancy. As the NHS sees the condition as a normal physiological process, rather than one that leads to a medical condition, it does not offer funded treatment. Many of the changes that we see post-pregnancy are related to hormonal changes and the development in the body shape and size that take place during pregnancy, as well as subsequent breastfeeding. In this article I will highlight some of the more common conditions that affect women, and the changes they see that are sometimes considered unfavourable, which lead to a consultation at a medical aesthetic clinic. The article will specifically not discuss the gynaecological changes that occur during and following pregnancy.
In order to understand what happens after pregnancy, it is important to understand some of the inherent properties of the skin. These properties change and are affected during pregnancy, and so a level of understanding of the normal anatomy and physiology of the skin is vital to understand what happens, and why it happens, when pregnancy occurs. In the skin, the elastic and collagen fibres are arranged in a spring-like manner.1 When a spring is stretched to a certain level, it springs back to its usual configuration and returns to the same state that it was in, prior to the stretching process. If a spring is stretched beyond the point where it has the ability to return to its pre-sprung state, it remains permanently stretched, which is a state known as hysteresis. Accordingly, it will permanently enlarge and become loose and stretched. For this reason, we see loose skin around structures that have stretched, such as the abdomen, the breasts and any other areas where weight gain has taken place. Permanent loose skin after pregnancy appears because the tightly-wound collagen and elastic fibres have unwound beyond their ability to return to their pre-sprung state, and they have thus exhibited the characteristics of hysteresis.2 Collagen and elastic fibres can also tear and split. Therefore, when these fibres are stretched quickly, the collagen and elastic fibres cannot only unwind but can also tear. When they do so, the thickness of the dermis is reduced, an injury response takes place increasing blood supply to the area, and the quantity of elastic fibres and collagen in the skin decreases, forming stretch marks. Stretch marks are initially purple and thin due to the increased blood supply following the injury response. Afterwards, when the blood supply reduces, the stretch marks become pale and wide. In skin prone to post- inflammatory hyperpigmentation, the skin may become hyperpigmented and thinned.3 Increased pigmentation is a normal part of pregnancy. During pregnancy there are increased levels of the adrenocorticotropic hormone (ACTH), which is very similar to melanocyte-stimulating hormone (MSH).4 One of the hallmarks of pregnancy is the linea nigricans, the dark line of skin that runs from the umbilicus to the pubic region. This area of skin becomes hyperpigmented and, due to the increased levels of ACTH during pregnancy, women are prone to melasma and other disorders of hyperpigmentation.5 Lastly, the breasts increase in size in preparation for lactating, and the abdomen increases in size to accommodate the growing foetus. During pregnancy there is inevitable weight gain and an increase in fat stores in areas that may be resistant to subsequent diet and exercise, thereby leading to permanent pockets of unwanted fat. Now that we understand some of the changes that occur during pregnancy, we can appreciate some of the concerns that women will have when they attend medical aesthetic clinics.
Stretch marks may be pale, purple or pigmented, depending on the individual and what stage the stretch mark is at. Examination of an area of skin where there are stretch marks should note the number, colour, length, width and location of the marks. Accurate records, including high-quality photographs taken under standardised conditions, with a ruler scale, will allow comparisons before and after treatment. Purple stretch marks manifest themselves as a result of increased vascularity in the dermis of the stretch-marked skin, and recommended treatment for this would generally be a light-based procedure that reduces vascularity, for example a green or yellow intense pulsed light (IPL) or laser. With these wavelengths of light, IPL will target haemoglobin as a chromophore, thereby reducing the prominence of blood vessels. Stretch marks that are pale can have treatment to increase pigmentation within the skin. Treatments such as micropigmentation can add colour to pale skin, as it is a
method by which skin-coloured tattoos are carefully created in areas of pale skin, in order to darken it to match the colour of the surrounding skin.
Stretch marks are characterised by thinned skin and, unfortunately, it is not possible to completely eliminate the reduced depth of the dermis. Since that is the case, it is important to advise patients that the stretch marks will still be present, but we should be able to reduce their size and prominence. There are several non-surgical treatments that can thicken the skin: laser, microneedling, platelet rich plasma (PRP) injections and radiofrequency. All of these methods can be used to help thicken the skin to a mild degree. The laser treatment of choice for thickening the skin is a fractionated ablative laser, such as an Erbium:YAG laser, CO2 laser, or YSGG laser.6 This technology drills small holes into the skin and the injury elicits a repair response. As a result, the skin thickens to varying degrees, causing a reduction in the prominence of the stretch mark. Multiple treatments are required to reduce the stretch marks and a suitable time period is required to allow skin healing in between successive treatments. Microneedling includes treatments such as dermaroller, Dermapen, and the Dermastamp. These devices create needle-point entry micro-injuries in the skin. The skin heals quickly, but the injury elicits a repair and regeneration process, which thickens the dermis and creates a collagenesis response. Microneedling devices are available in different needle lengths, and the required length of the needle is one that will penetrate through the full thickness of the dermis, in view of the full thickness depth of the actual stretch mark. As with the laser, multiple treatments are required to reduce, not eliminate, stretch marks. PRP has been used to reduce stretch marks and there is anecdotal evidence of its efficacy. PRP involves taking a blood sample from the patient, separating the blood into its components in a centrifuge, extracting the platelets from the centrifuge and injecting the platelets into the dermis, using something similar to the Nappage technique, in which the injection is targeted at the junction between the dermis and epidermis. Platelets are involved in repair and regeneration of injuries and release growth factors. The release of these growth factors also elicits a collagenesis response, hence reducing the prominence of stretch marks.
As we know, ACTH levels increase during pregnancy and this results in melanocyte stimulation, melasma and darkening of the skin in certain areas. After pregnancy and the normalisation of ACTH levels, the melanocytes no longer undergo hyperstimulation. Accordingly, the level of melanin production normalises but, sometimes, patchy pigmentation remains.5 In such cases, hyperpigmentation can be treated with a number of different treatment options. Melanocyte stimulation can be downgraded with prescription and over- the-counter medicines such as kojic acid, tretinoin and hydroquinone. Lasers, such as the Alexandrite or Nd:YAG laser, can be used to reduce pigmentation and on-going use of cosmeceutical products also help in suppressing the overproduction of melanin.
During pregnancy, body fat distribution changes. In some cases, the distribution of fat remains altered even after parturition and some women will have a desire to restore their body shape back to the pre-pregnancy state. For pockets of fat that are resistant to diet and exercise there are non-surgical and surgical treatment options available. Non-surgical treatments include cryolipolysis, contact radiofrequency and non-contact radiofrequency devices. These give a mild to moderate reduction in the fat that is treated, for example cryolipolysis reduces pinch thickness by approximately 15-28% in the area treated.7 All treatment options must always be discussed with patients, even though the healthcare professional may not actually deliver those treatments.
In my opinion, liposuction remains the gold standard for fat reduction and body contouring. Liposuction consists of three main phases: fluid infiltration, fat energy delivery and fat extraction. Fluid infiltration can be considered to be absent (in dry liposuction), and with increasing volumes of fluid infiltrated into the area treated. The terms used for the amount of volume of fluid are: wet liposuction, superwet liposuction and tumescent liposuction. The next step, in which energy is delivered to the fat, is one of three options: laser, ultrasound or radiofrequency. Each energy-based system has its advantages and disadvantages (for example, some RF systems can be bulky) and different surgeons will have their preference based on a number of criteria. The energy-based delivery systems disrupt the fat cells, increase the amount of fat removed in relation to blood removal, tighten the overlying skin and sometimes emulsify and target the fat cells. Finally, the practitioner will remove the fat, which may be performed through standard liposuction or through a power-assisted liposuction device. Power-assisted liposuction transfers the repetitive mechanical force from the surgeon to a surgical device, reducing mechanical strain and stress for the surgeon.
One of the major changes that takes place during pregnancy is the size and shape of the breasts as they prepare for lactation. After pregnancy and lactation, breast glandular hypertrophy reduces and often women are left with lost volume in the upper pole of the breast, glandular ptosis, nipple ptosis and excess skin. In such cases, breast surgery for reshaping may be an option. In women who have simply lost volume, particularly in the upper pole of the breast, augmentation with breast implants is the treatment of choice for those looking to increase volume. If there is concomitant ptosis of the nipple, this may be combined with a mastopexy, in which the breast tissue is elevated off the pectoral fascia to secure it in a more cranial position, while simultaneously elevating the nipple-areolar-complex on a vascular pedicle to raise its position. This will be conducted either as a one-stage or two- stage procedure, particularly when the skin of the breast undergoes hysteresis. When this happens the skin will not retract back to its original state, leaving some redundant skin. Sometimes the breast tissue enlarges and remains enlarged, and a breast reduction may be indicated.
As a result of the developing foetus, the abdominal region stretches to accommodate the growth. The skin may develop stretch marks and these are often seen in the lower abdomen, between the umbilicus and the pubic region. The skin will usually show signs of failing to shrink back to its pre-pregnancy state, as a result of hysteresis, and an abdominal apron of skin may ensue. Sometimes the patient may have had a caesarean section, with a lower abdominal Pfannenstiel incision. If the skin at the site of such an incision is tethered down
to the underlying tissues, an abdominal overhang develops. The treatment of choice to reduce excess skin, particularly when there is a significant abdominal pannus, is an abdominoplasty. As part of the abdominoplasty procedure, any divarication of the rectus muscles may also be addressed with muscle suturing. In such cases, a preoperative assessment is made of the position of the rectus abdominus muscle. If the surgeon determines there is an increased width of the muscles in the midline, with reduced muscle function in this area, a decision with the patient may be made to bring the muscles closer together. In these cases, the lateralised anterior wall of the rectus fascia is medialised with an appropriately strong suture. The excess skin is excised and the abdomen is inevitably flatter.
In conclusion, there are several changes that happen as a result of pregnancy, and many of these changes can be addressed in a medical and surgical aesthetic clinic. These changes are normal and physiological and are all to be expected during pregnancy. If the changes concern a woman, then there are procedures that we can perform that may improve symptoms and improve their quality of life.
Mr Taimur Shoaib will discuss surgical and non-surgical methods for fat reduction and enlargement at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more.