Dr. Schulman

Glad you made it! The swelling is normal. As you can see, it can be very extensive. You have probably seen in some other posts, that I always warn people about trying to fit into their pants after liposuction - it never works! Make sure you point out the buttock difference to your PS - again, this is probably just swelling, but should make sure it is not a seroma. Seromas are more common inthe back and buttocks than in the front - this is why I always put drains in the back and buttock as well. I am sure it will be worthit in a few months.

Having your ovaries out later will not "mess up" anything. I suppose that your gyn means that you will have a scar in the middle of your abdomen if you need a surgery later (because that is how they normally do it). This is probably because he/she will be uncomfortable doing the surgery through your panniculectomy incision (which is lower, and horizontal). Basically, if you need something done later, just make sure that your gyn asks a PS to help them expose the necessary areas through this panniculectomy incision so you don't have any new scars. I routinely am asked to "make the incision and get exposure" in patients who have had previous abdominoplasty or panniculectomy, and now needs some other abdominal surgery. I think you are right that the gyn is not familiar with the PS procedure that you are getting. Don't worry about it. Good luck Monday!

It is not a problem to a preliminary consultation via email - keeping in mind that there is no substitute for seeing you in person and getting an idea of the quality of your skin and how I think it will heal after surgery. I will be able to give you an estimate for the cost and also the amount of recovery time you will need in NY. I would still have to see you face to face in a "real" consultation, but this "virtual" consultation is a reasonable first step. Given the power of the Euro compared to the dollar, I sure you will find that there is a real financial benefit in traveling to the US for surgery. Combining all three operations would be very ambitious. It does not mean that it can't be done, but it might be a difficult recovery, especially given the fact that you will be returning to Ireland after the initial healing process. I think that picking 2 of the 3 is a better option for a combined procedure. Without knowing exactly what the surgical plan is, I cannot tell you for sure how long you would need to stay here, but it will be in the neighborhood of 2-4 weeks. I will PM you my email and you can send me more specific information.

You should wait until your weight loss stabilizes - this may or may not be at your "goal". I am guessing that you will have about 10-20 pounds of skin, so your weight loss may stop a bit short of your goal of 143. It is possible to have the apron removed while you are still losing weight. This is only in extreme situations where the pannus causes too many problems that you just can't deal with. The downside of having the apron removed early is that it will onlybe a panniculectomy (no muscle repair) and cosmetically, the result is not as good as a tummy tuck. Also, because you are still losing weight, you may have some small healing/wound issues because of poor nutrition. You should also be warned that you will likely need a revision to a formal tummy tuck after the weight loss stops. So the bottom line is to wait until the weight loss stops and stabilizes. It should be only under extreme circumstances that you have something done sooner.

A "mini" tuck is designed for the person with a small pooch - like the thin woman who has had a few children. It removes the skin below the belly button, and tightens the muscle below the belly button. It does very little to improve anythng above the belly button. I have never seen someone who has lost significant weight who is a candidate for a "mini TT". It is true that if no muscle repair is done, the recovery is much easier (it is the muscle repair that hurts). I almost always do a muscle repair - even if you have never had children. This is because the muscle has been stretched from being overweight (you have extra fat inside the abdomen as well). Even if the muscle is in really good shape, it can often benefit from being tightened a little bit. This makes for a flatter abdomen and a much better result. A LBL can be split into 2 operations - the front and the back. I do this sometimes, specifically because like you said, each can be done as an outpatient. Most people find that the "back" is a much easier recovery (because there is no muscle repair). There is no problem doing this in 2 operations and yes, it is two recoveries, but overall it is probably easier than recovering from a LBL. Given the situation you describe, this may be the way to go for you.

I did some quick research - A cosmo facelift is a non-surgical facelift using contour threads. While "cosmo facelift" is trademarked by Assassa, similar techniques have been described by several surgeons going back many years. I personally have my issues with these "threadlifts" as I have had to operate on several people who have had these threadlifts by other doctors - most were unhappy with the results, and some had complications from the threads. A threadlift may give some improvement, but the improvements are temporary (the data shows that the improvement lasts only a few years, at most), and the costs are not as low as people think. I have yet to see a person who has lost significant weight in which a threadlift will give much improvement. While I say this, keep in mind that there are many satisfied patients out there who have had a thread lift. Please do your research. Make sure you go to a qualified doctor (a board certified plastic surgeon and member of the ASPS) because many docs doing this are not even surgeons and do not have the knowledge about the underlying structures of the face. There are many potential complications with this - just like with any procedure. You should know by now that I think safety is key. Do your research in the procedure, and the doctor.

I have never heard of the cosmo facelift, but there are many names used for facelifts (usually made up by the surgeon or his publicist). Using the term "major" or "mini" is misleading because it usually only refers to the actual skin incision. The problem is that the work on the SMAS that is needed to provide a natural looking facelift (not like the tight pulled looks of the 1980s) requires a longer incision. The mini-lifts have a smaller incision and ironically eliminate the part of the incision that is hidden behind the hairline. Liposuction under the chin and neck is commonly performed with most facelifts.

Without seeing you and the quality of your skin, it is impossible to to know if liposuction alone is enough for you. From what you are describing, liposuction may improve your lower half enough for you to be happy. The issue is whether your skin will tighten enough after liposuction. It might, given the fact that it sounds like it tightened fairly well from the weight loss. It is certainly a reasonable plan for some people.

It is really impossible to answer that question. My suggestion is to lose as much as you can, until the apron is just too much for you to handle. You should try to get almost 1/2 way - but it totally depends on how bad and how fast your apron gets.

Some people have an apron of skin that causes lots of problems and require its removal before much of the weight loss. This is a panniculectomy and will help eliminate symptoms of rashes, infections, etc. It will also help you move around an exercise - all things necessary for successful weight loss. Int his case, a panniculectomy can be done, knowing that you will liely need a full TT (or LBL) after the weight loss. This staged approach is not uncommon.

The added weight is absolutely just fluid! I always tell my patients not to even look at a scale, let alone get on one. Even when I remove 10-15 pounds of skin, it is common for the person to be 10 pounds heavier because of swelling and fluid. It is important to keep drinking liquids and limit your salt intake (avoid soups that have a lot of sodium). As your swelling goes down, you will see your weight drop also. This might also make you have to urinate alot as your body gets rid of the fluids.

Glad you are feeling better. I usually have my patients empty the band prior to plastic surgery specifically for this reason. Also, I think it is important to get high nutrition prior to (and after) plastic surgery. It seems to me that your PS should be able to empty the band. It is not difficult and I am sure he can discuss how to do this with your bariatric surgeon over the phone. It does not make sense to me that you are so uncomfortable (and vomiting) until Monday. PS routinely fill and unfill similar devices such as breat implants, tissue expanders, etc. And a PS experienced with bariatric surgery should be comfortable with how the band works - just my 2 cents! I have my patients where the support garments all the time for 4 weeks. It helps both to reduce swelling and support the muscle repair. Then I have them wear them as much as possible (about 12 hours) for weeks 4-6. After that, they can go without, but most of my patients prefer to continue wearing an abdominal garment - they say it just makes them feel better and more supported. Your PS may have different recommendations so be sure to check with him.

1. A LBL always includes a TT, buttock lift, and outer thigh lift. If you only need the back done, it is possible to just get a buttock lift and outer thigh lift, without the TT. This would technically not be a LBL, but rather a buttock/thigh lift. Basically, it would be the back part of a LBL incision. This does not prevent you from getting a TT in the future. WHile it is unusual for someone to only need the back done, and not the front, it does happen occassionally. 2. I think that if kids are in the plans within the next few years, than waiting for the TT is reasonable. You are right that the belly will stretch out a bit, and many people have a small revision after the kids. 3. Scars can be "stuck" from adhesions to deep tissue. This is very common and can be seen in any scars. There are ways to fix this without a TT. You can have a scar revision in which the adhesions are cut and it will no longer appear "stuck". Sometimes, fat or other things can be placed underneath to correct a divot. 4.see#3. No 5.Many procedures can be combined. I routinely combine TT with breast lift/augmentations - in fact, I just got out of the operating room for this very procedure. Combining procedures depends on your health, motivation, and skill of the surgeon. I prefer to not combine another procedure with a LBL because it is a big operation itself and requires a lot of recovery. It would be dangerous to add to this procedure.

It concerns me that you are having so much pain 3 weeks after surgery. Most people still have soreness, but it is rare to need any strong pain medicine at this point. Also, the nausea/vomiting that you describe may be a sign of something wrong with you band (slippage?) Some people do get nausea fromt he narcotic pain medicine, but this sounds like something different. I would obviously call your PS for evaluation. I would not take more pain medicines until you have verified that there is nothing else going on. Pain can be a sign of a problem, and you don't want to "mask" the pain and possibly delay diagnosis of something. You should call your bariatric surgeon also, to have your band checked. Please keep us informed about what happens.

I do about 10-15 facelifts per year. All the facelifts include a necklift. While the incisions are the same, a face + neck is a larger operation than a neck alone. I think it does make sense to have a facelift at the same time as a necklift, but only if you need it (some people do only need a necklift). It is also common to have a chin implant placed at the same time - this tends to help with neck contour in people with a small chin (you can see pictures of this on my website). The surgery is ambulatory, and I would see you the next day. It makes sense to stay in the city for a day or two to avoid traveling, and also in the rare case that there is a complication. My office can arrange for a discount at a local hotel if you desire. You would then be seen on post-op day 5 (or 6), post-op day 12 (or 13), and then about 2 weeks after that. You will then see me about 2 months later to make sure everything has healed well. Obviously, the schedule of appointments is just a guide, but you can expect to see me about 3 times within the first 2 weeks. I routinely operate on people from out of town, so I am sensitive to your convenience (as long as it does not interfere with your safety!)

A neck lift will help tighten the muscle of your neck, and also the loose skin. It will not do much to improve your jowls - for that you need a facelift (which includes a necklift). The incision is around the front and the back of the ears (same as for a facelift) and probably a small incision under the chin for tightening the muscles. The recovery is much easier than body procedures. There is minimal pain, and swelling is the major issue. You should expect to be bruised and swollen for anywhere from 5 days to 2 weeks. A necklift is the same, whether it is done for aging or after weight loss. I do not have a name of anyone in CT but you should check the ASPS website (www.plasticsurgery.org)

It is ok to take a sleeping pill, if it is something that you have taken on other occassions. I don't think that you should take anything that you are not used to - it is never good to try something new, the night before surgery, and on an empty stomach. You would hate to have a reaction to something and then have to reschedule the surgery. Try to relax (easier said than done) and have confidence in the decision that you have made. Try any relaxation method that you think will work (deep breathing, meditation, tea, etc.) You will get medicine before the surgery that will make you very very relaxed. Good luck.

The term "extended TT" is kind of a misnomer. Technically, there is a TT, a circumferential TT/belt lipectomy (if it goes all the way around), and a LBL (if it includes a outer thigh lift and buttock lift - although some consider a circumferential TT and a LBL to be the same). If the TT incision goes to the side of the hips (longer than a regular TT) but does not go all the way around, than it can be called an "extended TT." In my experience, anyone who has lost significant weight ends up with what you would consider an extended TT. The problem is that these terms are not universal (and I am not sure it matters). If you call a plastic surgeon's office, the person answering the phone may not understand what an extended TT is. The main thing to ask is if he/she has experience with people who have lost significant weight through bariatric surgery.

This thread got quiet all of a sudden....you mean to tell me that I have answered everyones questions already?

Patricia, I came across your post and wanted to give my advice. I understand the desire/need to have your surgery in Mexico. There are many good surgeons there, and for the most part the surgeries are without complications. The problem is the post-op care. Also, most complications are not obvious until a few weeks later - long after you have returned home. Regarding drains, they are usually removed before you return home. Because people do not usually stay in Mexico for a long time (a few days to a week), there is a tendency to remove the drains a little early. In my practice, the drains stay anywhere from a few days to 2 weeks (the more weight you have lost, usually the longer the drains need to stay because your body makes more fluid). If the drains are removed too early, you can have problems with Fluid buildup, infections, or wound healing problems. If you develop a problem when at home, you then have to find a PS who is willing to deal with someone elses complication. Just last month alone, I was called to see 3 people in the emergency room who had complications after TTs in Domincan Republic. I think all 3 problems would have been avoidable with proper follow-up care. A GP may not be willing to provide the post-op care for your surgery - and honestly, I am not sure how qualified they are to do so either. I guess my advice is to be careful. If you must travel for the surgery, make sure you can stay as long as you need to - do not rush back home, because it may hurt you in the long run. Also, make sure you arrange BEFOREHAND to have a qualified doctor assume post-op care. Do not assume that if you show up to your GP with stitches, he will agree to take them out and provide care.

None of those things will improve your skin's elasticity. The most important factors are younger age, less overall weight loss, longer time losing weight, good nutrition during weight loss (protein), and GENETICS. All those things you list may make you feel better, and make your skin smoother/shinier/etc. but won't affect elasticity.

Your weight should be stable for a minimum of 6 months - even if it is short of your goal. (2 years is a very long time to wait).

Obviously, I cannot tell you for sure without seeing what you look like, but it sounds like you may not need a vertical incision - not everyone does. When done correctly (especially when combined with some liposuction), a TT can give a great shape. It seems to be that people who have lost massive weight tend to get a better shape when a vertical incision is added. But like I said earlier, this is still only about 1/3 of my patients. To be honest, I do much fewer fleur-de-lis in band patients, as compared to gastric bypass or duodenal switch patients - I think because band patients tend to lose less weight and over a longer period of time - 2 things that help the skin tighten after weight loss.

The exercises may help, but often do not help enough is there is significant laxity. There are some procedures available for vaginal tightening. I do not perform these in my practice (I do labial reduction, but not vaginal tightening). The procedure is a vaginaplasty and is most commonly done by gynecologists (there may be a few PS who do this, but it is uncommon).

The fleur-de-lis absolutely gives a better shape - narrower waist and reduces the likelihood of giving a boxy look after TT. The trade-off is a long, visible scar. Many PS do not do this operation - but this doesn't mean that this operation is unnecessary. For those of us who have a lot of experience with weight loss patients, sometimes this operation is the only way to give the best result. I don't do it for everyone, because not everyone needs it. I do it about 25% of the time. Probably 33% of my patients would benefit from it, but some do not want the extra scar - and I understand that, so I let them make the decision. Regarding implant incisions, it is really just preference. The scar around the nipple is well hidden - if it heals well. Sometimes, people make bad scars and if this happens, the bad scar will be right in the middle of the breast. By placing it underneath the breast, the scar is hidden (even if it heals badly). About 2/3 of my patients chose to have the implant placed from under the breast, but like I said, it is entirely personal choice. In theory, placing it from the nipple may slightly increase the chance of having decreased nipple sensation afterwards. If you need a lift, in addition to implants, then the incision can be placed in an area which is convenient for the lift - as to avoid 2 separate incisions.