Dr. Schulman

I thnk this was also brought up on the "Ask Dr. Schulman" thread. While it is best to have a TT after you have all your children, there is no danger to you ro the baby if ou get pregnant after a TT. Pregnancy after a TT may reverse some of the results - the belly skin will stretch, the muscles will separate. These are all things taht happen normally during pregnancy - regardless of whether there has been a TT or not. The disadvantage is that your stomach may not be a "good" as it was after the TT and may require a revisional surgery. Many of my patients have gotten pregnant after a TT. Some of them are still happy with what their bellies look like afterwards, and some request small revisions. IT really depends on how your body reacts, but like I said, it is not dangerous to you or the baby.

I know of Dr. Katzen. He has a good reputation and the majority of his practice is related to weight loss surgery. He has a strong following of patients. He tends to be a bit on the aggressive side - long surgeries, and massive liposuction, etc. It is common for him to suction 10 L of fat from the legs before he does the LBL a few months later. I personally think that this leads to long OR times (8-9 hrs) and up to 1 week in the hospital, with increased complication risks. The data clearly shows that OR times exceeding 6 hours and liposuction exceeding 5 liters significantly increases the risks of surgery. While this very aggressive approach is not my particular style, Katzen gets good results and his patients tend to be happy, so I guess it works for him. I know the prices can be signficant as well given the extensive surgery, hourly rate for the OR, and overnight hospital stays. Regarding the time in the OR, every doc is different. Some work fast, and some have people helping them which enables them to cut down the OR time. Personally, I think 2-3 hours for an extended TT and breast lift with implants is way too short - I would be concerned that one person is working on the breasts while another is working on the abdomen. You should be sure of who the person is helping! I always do this surgery with a plastic surgery fellow (or two) and sometimes another board certified surgeon with me - I never have a technician or a nurse doing the surgery with me. I get paid for my skill and training, and it is not fair to the patient to have someone else perform a major portion of the operation. I consider myself fast, but it would take me about 2-3 hours for the TT and then another 2 hours for the breasts - for a total of 5-6 hours. Hope this helps.

Congratulations on your weight loss. I happen to be a huge fan of the the vertical insicion/anchor incision/fleur-de-lis TT. Yes, it involves more scarring which is its major drawback. The advantage is that it can really improve your shape. It will narrow you in the waist and give a nice hourglass shape - which is not possible with just a horizontal incision. Regular TT have a tendency to make people look "boxy" if they are having a lot of skin removed. It is hard to say how much narrower it will make you (in inches), because it narrows the waist, but not he hips, thus giving the hourgalss shape. I am guessing that most people would say that it will make the waist many inches smaller (maybe 5 - but it is hard to generalize). The main advantage is shape, not size. If you are willing to accept the scar, the results are great. Also, because when I do this operation, there is LESS disruption of blood supply, I can do MORE liposuction. I know it seems like it would be the opposite but it has to do with the surgical technique.

Sorry you have had a rough time. I am not too familair with Northern Ca plastic surgeons. I have heard the name Eric Mariotti tossed around. He is in Concord (I am not even sure if this is close enough to you). He seems to have decent reviews on Obesity Help, but I cannot vouch for him personally. I will ask around and if I hear of someone, I will let you know. Most of the people I am familiar with are more south. If you are willing to travel, you should see Sue Downey in LA. I know it is far from you, but it is not as far as NYC!

For my patients that are coming from a long distance (or out of the country) they usually stay in NYC for a minimum of 2 weeks. This can be longer if they have an extensive surgery or are slower to heal. I require that all drains are removed before returning to home. They then return for followup 2 weeks later for a followup visit. I understand that it can be a real comittment if you are having a major surgery like a LBL. In southern CA, I recommend Ed Domanskis in Newport Beach 949-640-6324. His practice is dedicated to weight loss patients almost entirely and he is excellent.

Just another reminder..... Please tune in for The New You Internet Radio Show tomorrow evening (Wednesday, August 18, 2008 8pm-9:30pm) where I will be the featured guest. I will be discussing how to choose a plastic surgeon specializing in body contouring after weight loss, as well as the specific procedures available to you after successful weight loss. I will be taking LIVE callers (so keep it clean!) and there is an online chat room during the show. I would love the support, and it is a great opportunity to ask the questions that you have always wanted to. Bookmark this link so that you can listen to the show live and participate.

I had to chime in ont his one.... The website allows people (men) to "meet" women who want breast implants. They "meet" them online in chat rooms, exhange photos, etc. in exchange for donations towards the woman's breast implant fund. Once they are put in contact with each other, they are free to do whatever they want. It is a very slippery slope and although unethical activity is not encouraged...it is nto discouraged either. From another perspective, the women are then put in contact with a surgeon who will perform the breast augmentation. These surgeons are often under qualified, not board certified plastic surgeons, and many are not even plastic surgeons at all! The enitre set up is very very shady. In fact, it has been reported to the American Society of Plastic Surgeons and althought the ASPS cannot regulate this site, it can discourage its members from participating (ie. getting referrals from this site). Some have even proposed that ASPS members affiiated with the site be kicked out of the society. My advice is to stay away.

To be honest, if you are 178 and only 28 pounds from goal, it is possible that you are very very close to goal when you factor in the extra skin. I routinely remove 10 or more pounds during a tummy tuck (obviously depending on each person's excess skin and I have removed up to 45 pounds from an abdomen!). Also, a breast reduction from LL to C will likely require the removal of about 4 kg of tissue or about 10 pounds. So, you are very very close. This is why people's "goal" weight can be misleading, becasue it does not take into account the weight of the excess skin. Several operations can be combined - assuming you are in good health, and your PS is experienced in weight loss patients. Age itself is not the main factor. Some of my 60 year old patients are in better health than my 30 year olds! I would have to see you to really develop a surgical plan, but it might make sense to start with a breast reduction. A 36LL is very large given your 5'4" frame. A reduction would help you exercise and you will be surprised how the weight loss will "jump start." A breast reduction can be combined with an armlift or a TT. IF the surgery is performed as ambulatory, you should expect to see your PS the following day, and then once a week for weeks 2, 3 and 4, then once on week 6 and week 9. This is jsut a rough guideline and depends on exactly what procedure you have done and how well you heal. I am not sure where you live, but I would love to see you in NYC!

It sounds like liposuction is a great option in your case. Because it has been a year since your TT, you can have aggressive liposuction with minimal risk for blood supply problems that we have talked about. This will significantly improve all the areas that still bother you. It sounds like your PS really understands the "staged" approach. Regarding VASER vs smartlipo: VASER is ultraound-assisted liposuction (UAL)which has been arond for about 10 years. It works well and the jury is still out whether it works any better than traditional tumescent liposuction. The theory is that the ultrasound waves breaks up the fat easier and does less destruction to the normal tissue. It generates a significant amount of heat - this has been blamed on many instances of burns to the skin (from the inside). These burns are the reason why UAL fell out of favor over the past several years. VASER is a system that uses UAL, but claims to have less incidences of the burns of yesteryear. I think it is much safer than the older UAL systems, but like I said, I am not convinced it is better than regualr liposuction. So, if your surgeon is experienced with it, there really is no reason to avoid it. It will actually work better for thick, dense tissues. Does it really tighten the skin? Probably not. SmartLipo is laser-assisted liposuction and is designed for small areas - neck, face, small spots on the sides, etc. There is a post on this thread which goes into more detail about my feelings on smartlipo. Without being too harsh (again) I think this technology is nowhere close to traditional liposuction (or even UAL). I think the attention that smartlipo got in 2007 was media-driven. There were very few plastic surgeons using it - most were ob-gyns, dermatologists, family docs, etc. In fact, you don't hear too much about smartlipo anymore, do you? There are short scar brachioplasties which limit the incision to the underarm (armpit) and don;t have the scar running to the elbow. This is a great operation for those with only small amounts of excess skin. Pull your skin towards your armpit - if this improves the appearance, and satisfies you, than you may be a candidate for this short scar procedure. I do about 50 brachioplasties a year, and only about 15% are short scar.

My August email newsletter just went out today. For all you who signed up, I hope you are enjoying it. If you have not signed up yet, and would like to be added to the list, you can sign up on my website. I will be resending the August newsletter next week.

There are 4 factors that impact skin laxity after weight loss: amount of weight you lose - greater than 100 pounds is considered "massive weight loss" rate at which you lose it - under 1 year is considered "rapid" age - younger skin is more resiliant to weight loss and can "shrink" better genetics - this is the mystery factor and has a lot to do with it. So in general, weight loss of 85-90 pounds over the course of 1 year in a young individual will likely lead to good "shrinking" of your skin. But, as many on this board will tell you, you just never know.....you will jsut have to see how you respond. Keep your nutrition level good during the weight loss period.

I perform autologous augmentation of the buttocks. The key is that the tissue is never separated from its blood supply. It is not fat injections, but rather a fat "flap." My patients have been happy. It gives a longstanding result - unlike fat injections which lose around 50% of volume after the first several months. Also, my patients do not need to avoid sitting for 2 weeks as is the case after fat injections. I think you are correct that this is not that common, but it is increasing in number. I will try to get you some other photos of this procedure.

You can do this in any order. I ask my patients what bothers them most, and the answer will determine the order. A LBL is the largest of the procedures and usually requires the most recovery. This tends to be a good place to start, because it usually "jumps starts" your weight loss again. It also gives the most dramatic improvement. You can then proceed with the arms and breasts which do very well combined. Also, if your surgeon is very experienced, and you are healthy and motivated, you may be able to do the inner thighs at the same time as well. Again, the order is determined by you - what bothers you most, the amount of recovery you will need, and financial considerations.

I am just curious about the "all be on him" statement - usually, when PS need to perform revisions, they will forgive the surgoens fee, but usually the patient is responsible for the anesthesia and facility fee. You may want to double check this with your PS. It would be unusual for your doctor to pay the anesthesia and facility fee as well as not charge for the surgeons fee. About the implants, just ask him "if the revision that he is doing will result in upper pole fullness, or will you do better with a small implant at the same time". See what he says. I suspect he will tell you that an implant may be necessary, but yuo should wait until everything is healed and the breasts take the final shape in ablout a year - at that point an implant can be added if you are still unhappy. It becomes a complicated procedure because it is a revision of something done fairly recently.

There are several excellent plastic surgeons in the Houston area. You might consider John LoMonaco - he is very experienced and talented. You will find several people on this site that would agree.

Thank you for the kind words. Out of all my different types of patients, I find the weight loss patients the most motivated and helping them is extremely rewarding. Please excuse the plugs...... I will be on "The New You" radio show Wed. Aug 6th. You can listen online live and there is a live interactive chat room and live callers. It would be great to have everyone's support and also I will be able to answer your questions live. For those of you who have listened to this show before, it is very entertaining and very interactive. I also hope to see all you east coast bandsters at the Walk From Obesity event in NYC, Sept., 28th. Stop by my table so I can meet you. I will have lots of goodies and pictures. I hope to see all of you there for this very worthwhile event! I have also gotten some pms asking me to re-post the link to my last radio appearance on the "Health and Beauty Revolution." Thank you to everyone for the great feedback about that appearance. Here is the link.

PEs are rare, so I would not bother trying to find a PS who has operated on someone with a PE - they may be hard to find. You should consult with a hematologist and you may consider having a filter placed at the time of surgery. You should also be given blood thinners prior to and after surgery. These are all reasons for your surgeon to be extra carefull.

Medications like yours DO affect potential PS. The medications put you at significantly higher rate for potential bleeding complications. You can have surgery, but in your case, make sure you select an experienced PS and only do the surgery in a hospital - not in the surgeon's office! Also, while I routinely combine multiple procedures, you are best to do multiple surgeries. You will be at less risk for complications if you have smaller individual surgeries as opposed to one large combined one. Your health and safety is obviously most important and you will be able to proceed with PS if you want, but you must proceed with caution.

The scar from the gyn surgery is not an issue at all. In fact, the majority of my patients have a pre-existing scar in that area (s-secction, etc.). This is removed with the PS - eith an panni, abdominoplasty, or LBL. The Scar from the kidney surgery is a little more of an issue. Because of blood supply issues, it may interfere a bit with PS - it may limit the amount of tissue removed in that area, but this really depends on exactly where the scar is (your PS will evaluate it when the time comes). Either way, this kidney scar can be revised - it can be redone by your PS and made to look nicer. Hope this helps. Good luck with the weight loss

I have a very good relationship with many bariatric surgeons throughout the country. I also speak at bariatric surgery support groups throughout New York and New Jersey. Insurance will pay for reconstructive procedures or procedures that are medically necessary. Much of plastic surgery after weight loss is still considered cosmetic unless you can demonstrate a true medical need. Usually a panniculectomy is considered medically necessary - if you have chronic skin irritation, rashes, infection, etc. If you look throught this thread, you will find many posts about this topic that can tell you more specific details. You can also obtain this from your insurance company when the time is nearer.

Don't be depressed! You can't judge everyone's result by one bad one. Armlifts, when done correctly, can give excellent results with very high patient satisfaction rates. It is true that sometimes people get bad scars, but this is true with any surgery (there are some bad surgeons, and some people are "bad healers"). When done correctly, arm lifts can give a natural appearing arm, without the "med flaps." A well placed scar is only visible whent he arm is raised. It will not be visible from the front, back, or side. If you are interested in an armlift, my advice is to search out a well qualified plastic surgeon, experienced in post bariatric body contouring. Don't be discouraged because you saw one bad result. Best of luck to you

First, just because your PS does not "participate with insurance", does not mean that he can't submit the paperwork for you, and then you will receive reimbursement from the insurance company directly. You may meet criteria for reimbursement because your doctor suggested you get a "tape test" - or visual fields. Second, if it was your PS who sent you to the eye doctor to get the test, it is highly unethical for your eye doctor to try to solicit you. It breaks many "unwritten rules." In order to provide the best possible patient care, we refer patients to specialists. If doctors become fearful that the consultant will try to "steal" patiets, then docotrs will stop referring, and this is not always best for patient care. This may not be how things happened, but if it is, and you have a good relationship with your PS, then I would let him/her know, so that they can find another eye doctor to refer to. In terms of who is better - obviously, I am biased. PS have a minimum of 6 years of surgical training. Opthomologists do not have any blepharoplasty training unless they do a one year occuloplastic fellowship. That being said, there are some bad PS and there are some excellent opthamologists (make sure they are an opthomologist, with occuloplastic training! - if they don't, then they are not experienced enough to do eyelid surgery)

I can't really tell you which companies have a better history of paying, because it is always changing and often not consistent within companies. Also, it is very likely to change again before you are at a point for plastic surgery. The best thing to do is have your primary doc (not a plastic surgeon) document rashes. Also, make sure you get (and fill) a prescription for an anti-fungal cream or powder. Insurance companies will look for these prescription records because they know how easy it is to "document" rashes that are not always there. It is common to have hernias that can be fixed at the same time - it is not a bad idea to get a CT scan and if a hernia shows up, the insurance company usually recognizes that a panni needs to be done in order to fix the hernia. Lastly, it comes down to picutres. Most companies require that the pannus hangs at or below the level of the pubic bone - if it is not there, they usually will not pay, even despite all the other things mentioned above.

Sorry for jumping in here...but I just can't resist.... There is no clinical evidence that any of these lotions work. In fact, read the fine print and you will notice that it usually says, "clinically provent o reduce the APPEARANCE of cellulite...blah...blah...blah..." Like others have said, these creams work by moisturizing. By "plumping" the skin and underlying fat, it may make the cellulite and dimples appear softer. Believe me, if any of these things worked like they claim, I would be bathing it it myself! I think they are very good moisturizers, and in the case of nivea, not very expensive. Feel free to try it, but be realistic about what it can do for you. They certainly are not harmful to you.

There are several models available. They are not as powerful as "professional" models, but I am not sure that means that they don't work. No studies have been done on these lower energy models. They are not very expensive (usually around 100-200) so there is not that much to lose....but I am not sure. The professional models work, but are very expensive (usually around 1500 and up) and they are still not as good as ones in the Dr's office. You don't need to do the LEDs that often - usually every 4 weeks, so it makes more sense to find an aestetician that does it, get yourself a nice microdermabrasion and facial, followed by LEDs every 4-6 weeks. You should be able to get this for about 200 per treatment session, and you save money if you buy packages of 4 or so. The cost is more than buying the LED machine yourself, but it is great for your skin and you get pampered.