Dr. Schulman

I thought that this might be a good place to post questions to me, so that other people can see your questions and my answers. I will continue to answer questions from those of you that private message me, but this is a nice way to share the information with others - since many of your questions are relevant to other people. I will try to answer the questions as quickly as possible, and include links and pictures when appropriate. I am obligated to add this disclosure.....any information provided by me is my opinion and cannot substitute for an actual consultation with your qualified physician.

Never heard of it!

You are right to be concerned about saggy skin remaining after inner thigh liposuction. This is a very common result if liposuction is done in someone who needs a thigh lift to remove the excess skin. Yes, age does matter, so the younger you are, the better chance you skin has of recovering and tightening. But, in my experience, even the young patient who has had significant weight loss has skin that lacks elasticity and will not tighten up fully. I have been very happy with laser liposuction in this area in particular which helps the skin tighten up a bit more than traditional lipo.

Sorry Suzanne for the delay - I must have missed your post! Massive weight loss is the first criteria for insurance coverage. Usually this means 100 pounds, but it also depends on your height and original weight (100 pound weight loss in someone who is 5'10" is not as much as 75 pounds in someone who is 5'0"). You should get documentation of the rash, even if it is small. See your GP first and usually this is sufficient. There should be precriptions that can help you. Also, if you call your insurance carrier, they should be able to give you a detailed list of requirements to prove medical necessity for a panniculectomy.

Congratulations on your weight loss. Make sure you check out the "Ask Dr. Schulman" thread - you will probably find good information that will help you in your process. If you are interested in coming to NYC, you are more than welcome to come see me. Regardless of who you choose, make sure you select someone experienced in body contouring after massive weight loss - this really is a very specialized area of plastic surgery.

It is true that there can be a moderate blood loss during a LBL and being anemic can affect your healing. Iron deficiency anemia is very common, and even with iron supplementation, it can take several weeks to get your count up. This is because it takes your body that long to produce blood cells. If you have not seen a hematologist, make sure you do. He/She may have other recommendations that may help you. make sure they have checked your b12 and folate levels as well. One other thing to consider if your count still remains at a safe, but low level is that you can always split the LBL into 2 operations - a front and a back. This will greatly reduce operative time and blood loss.

Congratulations on your weight loss. Regarding the consultation, as I have said in the past, it is never too early. If you are considering surgery around Christmas, then you should certainly come see me in October so we can work out a surgical plan for you. Without seeing you, it is impossible to say what you may need, but a LBL is among the most common needs of someone who has lost weight like you have. I am unclear from your post if that extra roll under your bra line is in the front or the back. If it is in the back, you may need this removed from the upper back with an incision that remains in the bra line. Also, you mentioned that your breasts have gotten smaller, so you may be interested in a breast lift with implant. A three week recovery should work well for you. You will need to stay in the area for a little while afterwards, and my office can help you in arranging a nearby hotel. Obviously, after I see you, we can come up with a very specific plan that meets your needs. I look foward to seeing you.

A dog ear excision is a relatively small procedure that can be done in office with local anesthesia. Most plastic surgeons will remove this without charging the patient because it is really a "touch up" from the abdominoplasty. They may or may not submit it to insurance, but will likely not get any reimbursement from this "cosmetic" procedure. I do not think that weight gain contributed to this dog ear.

There is no reason to avoid flys - unless yo notice that the implants move when the muscle contracts. Most people do not have a need to do chest exercises after breast implants because as most of you know, women tend to do chest exercises to make the breasts look bigger - which is no longer an issue for you.

Obviously, I am very late on this answer (so hopefully you did not have any problems). Most complications happen within 2 weeks, but keep in mind that things can happen later, especially when people begin to be more active and may tend to "overdue" things!

depends what type of work you do. If you usually sit at work and do not have to lift anything, then you may be ok in 2 weeks. It also depends on how well you heal. It is true the the TL is the toughest to recover from, but I have many patients who are back to work in 2 weeks - I also have many that need longer!

There is no way to predict whether or not you will need plastic surgery (incidentally, "need" ir really "want"). It depends on the quality of your skin, your genetics, the amount of weight you lost, the time it took you to lose the weight, and many other "unkowns". The best you can do is prepare for the possibility and see how it goes.

You left out the most important detail - are you still losing weight? If your weight has stabilized (even if you are short of your "goal") then you are ready for surgery. I suspect you have at least 15-20 pounds of extra skin, so you may be essentially at goal. It can never hurt to see a plastic surgeon early.

As many of you know, I often speak at bariatric support groups in New York and New Jersey. One thing that never fails to amaze me, is how many people are surprised at the body changes after bariatric surgery. Many people had no idea that the skin may remain after weight loss and that needing (wanting) plastic surgery is extremely common. Patients are much more educated now about PS after weight loss - through support groups that sponsor plastic surgeons, through websites like this one, and in speaking with their bariatric surgeons. There is always room for improvement - especially on the "pre-op" side, so that you know that the weight loss may not always be the end of your journey. I am interested to hear your thoughts about the way in which you were educated about plastic surgery (or not educated), and whether this occurred before or after your band procedure. This will help me be able to better educate people about this subject.

Weakening the muscles of the forehead without removing excess skin (brow lift) is usually not a good idea. You can see why. The muscle can no longer suppot the forehead and the skin will get even more droopy. I sounds like you needed a browlift with either a fhairline excision to remove the excess skin or endoscopically to pull the hairline back an inch or tow. There is no medical reason why this was not done but it sounds like this was not completely discussed between you two before. I cannot stress enough how important clear communication is between surgeon and patient - this may have nothing to do with a language barrier. This can be fixed but will require a surgical procedure after 6 months to allow the tissue to heal. Obvioulsy, you should discuss your disappointment with your surgeon on your followup visits.

Congratulations on your weight loss. I think that it is possible to return to a sit down job at 3 weeks after a LBL - barring any complications.

There is very little that can be surgically done to improve the calves - there are too many important vessels and nerves, and incisions in the lower leg can cause severe and prolonged swelling. Excision of some of this skin may help, but you will be left with a visible scar and the improvement may not be as good as you want.

A reductin always includes a lift...so it would make no sense to get a reduction + implants for a lift. It is hard to determine the exact weight of your reduction ahead of time. It depends on the amoutn of fat or breast tissue in the removed specimen. I have done many many reductions and still find it difficult to guess the exact weight - I give ranges ahead of time, like 300-500g, 500-700g, 800-1000g, etc. I agree that if you are a D, than anything smaller than a C cup will probably make you feel "too small." I ahve many patients who tell me then want to be a "b" but are suprised when I show them how small a B would be on them. Everything needs to be in proportion.

Blood loss is minimal with both of these surgeries. As long as your primary doc and hematologist thinkyou are ok for surgery, then it should be fine. However, Lupus or not, I think arm lift and thigh lift is a really tough combination in terms of recovery - it can be done, but as I have said on this forum before, it will be difficult for you.

Combining surgeries is ok. I routinely perform breast surgery at the same time as the tummy tuck. Regarding liposuction - extensive lipo at the same time as a TT can injure the blood supply of the tissue and increase your risk for complications. Most surgeons do a moderate amount of lipo on the flanks at the same time as TT, but do not do lipo of the upper abdomen because of what I said above.

I think that all three procedures can be combined, but keep in mind that the recovery will be much more difficult. It will be hard having the tummy tuck and lipo at the same time. Lipo of the legs is more painful than other areas and the swelling can be significant. If you were to split it up, a good combo is the TT alone, and the breasts and lipo together (in whatever order you desire). "Recovery Time" is difficult to answer, because everyone heals differently, but at least a few weeks... It is true that the better shape you are in, the better you will recover. Good luck to you.

Lipo of the this and a breast lift can be combined (and often is). Most people can go back to work in 1 week after lipo of thighs, assuming that they have a desk job. In your case, you will probably need 2 weeks off (especially if a breast lift is combined).

I am glad verything went well with your daughter. I had no doubt, Dr. LoMonaco is an excellent surgeon. She will need to specifically ask him what the time frame is for not sitting up straight. It is probably so she does not pull on the suture line and will likely be for a few more days. The short scar brachioplasty is good for people with mild to moderate skin laxity of the arm. In general it is not the optimum choice for weight loss patients, but we will have to see how your arms react to the weight loss. Exercise is good for you, but remember,t he problem is a skin issue, and you can;t exercise away skin... Good luck with your weight loss and I hope to see you whenyou get closer to goal!

You probably do not have to wait until your ideal weight, but I would like to see you get closer...maybe to within 30 pounds. I do not think that insurance will be an issue because as long as your diagnosis is breast cancer and acquired asymmetry of breast, you will be fine.

Most likely your thighs appear bigger becuase your stomach is smaller...it is very very common to feel this way. IT is possible they did get bigger though with swelling or more weight loss. Either way, the fact that you had such a serious seroma after places you at higher risk for a seroma after the thigh or arm lift (does nto meanit will definitely happen). I think that a thigh lift in you would be best with an overnight stay. This will give you 24 hours of bedrest and lower your chance of complications. doing the arms at the same time may be a very tough combination for you and would recommend against it,b ut talk toyour doc.