Ask Dr. Schulman...

[Dr. Schulman 2]

Hi Dr Schulman,

I was wondering what your views on mini tummy tucks combined with hernia repair were.

I have 2 incisional hernias at either end of my caesar scar which my GP says are nothing to worry about. However, hernia's dont get better, and these look a bit weird, they are visible looking down my body and they can ache a bit by the end of the day (they also make a really revolting squelchy noise when pressed, lol).

So I was thinking........ I couldnt really justify a full Tummy Tuck. I ahve a bit of loose skin and probably ne4ed a bit of Lipo on the residual upper ab fat pocket, but my muscles are rock hard, absolutely flat and are not separated.

If I were to be opened up to repair these hernias rather than have them done laparascopically, would it be an unusual thing to ask to just remove a crescent of skin from the lower belly and tighten it up without moving the navel etc?

I'm thinking there's a very very tiny possiblity that in Australia, this the anaesthetics cost of the op might then be covered partly by medicare due to the hernia repair comopent. Private insurance covers the hospital stay either way.

I think you ahve a good understanding of this and combining a mini with an open hernia repair is a good plan. You may not "need" it, but you already have a scar there, and you do have s small amount of skin laxity. Besides, while a laparascopic hernia repair is common now, doing it open allows them to really see the hole and fix it from the inside and outside.

I am not sure who is planning on doing this - ps or the surgeon ding the hernia repair? This is a simple procedure for a ps, but a general surgeon may not be able to (or willing to) just "remove a crescent of skin" and give you as nice a result as you are expecting. There are a lot of "tricks of the trade" that we do during a mini TT, and often there is a lot of work under the skin, even though the incision is small. All these things add up (hopefully) to a discrete scar and flat lower abdomen. We want want we do to "appear" simple, when it is really not. I am sure you can find a ps willing to do this for you at the same time as your hernia repair - it is actually very common to do this. Obviously, I strongly advice against having a non-ps perform any cosmetic procedure on you. I would never remove a gallbladder (even though I was trained in general surgery first and can probabably still do it) and I would hope that a general surgeon would never do a tummy tuck (even a mini).

[Jachut 487]

Thanks - yes I was meaning a PS.

[Dr. Schulman 2]

Thanks - yes I was meaning a PS.

Glad to hear that! Go for it....just keep us posted on how you do.

[karenlynn79 0]

Hi Dr. Schulman,

I am 15 lbs from goal and getting ready for a breast lift with aug and then a month later, a TT and inner thigh Lipo. I have a couple questions:

1) How can I prevent my aug from being too big! I have nightmares of this. Even though I have pictures and have tried on sizers, it's so hard to tell. Any tips??

2) My PS is very skilled and highly recommended by a doc friend of mine, but he didn't mention actually moving my port during the TT. He said he likes to get the muscles very tight and he'll have to be careful to move around the port, and he might not be able to go as super tight as he likes. Will it matter if he doesn't move it? If he's never moved a port, I am kind of nervous about asking him to do it! Or is it so simple that he could experiment on me by trying?!

Thank you!!!

Karen

[Dr. Schulman 2]

Hi Dr. Schulman,

I am 15 lbs from goal and getting ready for a breast lift with aug and then a month later, a TT and inner thigh Lipo. I have a couple questions:

1) How can I prevent my aug from being too big! I have nightmares of this. Even though I have pictures and have tried on sizers, it's so hard to tell. Any tips??

2) My PS is very skilled and highly recommended by a doc friend of mine, but he didn't mention actually moving my port during the TT. He said he likes to get the muscles very tight and he'll have to be careful to move around the port, and he might not be able to go as super tight as he likes. Will it matter if he doesn't move it? If he's never moved a port, I am kind of nervous about asking him to do it! Or is it so simple that he could experiment on me by trying?!

Thank you!!!

Karen

There are no real tricks to picking th right implant size. The key is to try on the sizers and see how you feel. Some docs will let you borrow the sizers for a few days and you can take them for a "test drive" - go to dinner, take a walk, wear them to work, etc, to see how you feel and see how people react. If you can't borrow the sizers, you can fill a baggie with dry rice and wear them the same way.

Regarding the port, it is not always necessary to move it. It is best that it be moved if it needs to be in order to get the best cosmetic result, rather than having a sub-optimal result. Your PS should be able to "figure it out" because it is the same port that is used in other things that he is used to (like some breast implants). He should have a bariatric surgeon available, just in case something bad happens to the port and he needs help.

[lherstine 0]

Dr. Schulman,

i have lost 130 lbs in the last year and 5 months. I have had pain in my port area and have had all kinds of tests done to be sure all is fine!! My surgeon is wonderful and has ruled out possibilities that could be problematic. We have determined that the excess skin and fat apron from my weight loss is causing muscle pull on my port:( i am going to a ps on march 5 to set up surgery. I have bcbs of michigan and am told that they should cover due to medical necessity. Do you think a pannelectomy or a Tummy Tuck would be advised? I would love a tummy tuck but not sure on insurance coverage? I would just like an opinion from you for when i go to the ps on march 5. I am excited to have either procedure done of course!! Lherstine

[Dr. Schulman 2]

Dr. Schulman,

i have lost 130 lbs in the last year and 5 months. I have had pain in my port area and have had all kinds of tests done to be sure all is fine!! My surgeon is wonderful and has ruled out possibilities that could be problematic. We have determined that the excess skin and fat apron from my weight loss is causing muscle pull on my port:( i am going to a ps on march 5 to set up surgery. I have bcbs of michigan and am told that they should cover due to medical necessity. Do you think a pannelectomy or a Tummy Tuck would be advised? I would love a tummy tuck but not sure on insurance coverage? I would just like an opinion from you for when i go to the ps on march 5. I am excited to have either procedure done of course!! Lherstine

Excess skin pulling on the port is a very common source of pain. In rare instances, it may cause slippage of the band or malfunction of the port. This issue should certainly be addressed. You basically have 2 options: 1) revision of the port. The port can be moced to a higher position so that there is no more pulling. This is the simplest approach and can be done by your bariatric surgeon. 2) panniculectomy. This would remove the excess skin, and should be covered by your insurance. Even if you have a panniculectomy, you will almost certainly need the port moved, or the "pulling" can get even worse. A tummy tuck can be done, but this is a larger procedure with more pain and more recovery. Also, insurance will not cover the added cost of a TT because it is always cosmetic (as compared to a reconstructive panniculectomy). Also, you should wait until your weight loss is stabilized before going throug a TT.

Keep us posted about what your PS says.

[mrskrzyz 1]

Is there a difference between an adminioplasty performed by a self-payer (cosmetic) or one done on a patient that insurance covers due to medically necessary???

I ask this because mine was approved by insurance. For a pannilectomy and abdominoplasty. My doc seemed to constantly remind me that this was reconstruction without the conturing done in a cosmetic procedure.

I feel he did the bare minimum. Although it looks better... there is still quite a large amount of bulk in the abdominal area.

Just wondering if a doc is supposed to handle the cases differently???? (self pay vs. insurance)

Thanks so much!

Thanks in advance for your answer.

[Dr. Schulman 2]

Is there a difference between an adminioplasty performed by a self-payer (cosmetic) or one done on a patient that insurance covers due to medically necessary???

I ask this because mine was approved by insurance. For a pannilectomy and abdominoplasty. My doc seemed to constantly remind me that this was reconstruction without the conturing done in a cosmetic procedure.

I feel he did the bare minimum. Although it looks better... there is still quite a large amount of bulk in the abdominal area.

Just wondering if a doc is supposed to handle the cases differently???? (self pay vs. insurance)

Thanks so much!

Thanks in advance for your answer.

An abdominoplasty is an abdominoplasty. Insurance never ever approves an abdominoplasty because it is always cosmetic. Most likely your insurance approved a panniuclectomy due to medical necessity (just removal of skin). The insurance reimbursement will be for a medically necessary panniculectomy and may be between 1500 and 2000 dollars.

If your surgeon did an abdominoplasty (which includes tightening of the muscle and relocation of the belly button) than he likely did it for "free" - meaning that he did extra work and did not get any extra reimbursement. Because it sometimes takes 3-6 months to receive insurance payment, he most likely does not know yet that he did it for "free." Even is he got "pre-authorization" from your insurance company before the surgery, this is not a "promise to pay." Unfortunately I have been down this road many times.

I cannot second guess the quality of your surgeon's work. I cannot jump to the conclusion that your surgeon took any shortcuts during the Tummy Tuck because he knew there was a good chance he would not get an payment for it.

So to answer your question, no - the case should be handled the same way. Surgeons must take pride in their work and produce the best possible results, no matter how much (or how little ) they are getting paid for it. No professional should knowingly put out a sub-standard product.

I am interested in knowing whether your surgeon really did get paid for a TT - like I said, I am willing to bet that he got paid only for procedure code panniculectomy..... You can easily get this information by requesting a copy of the EOB (explanation of benefits) from your insurance company. You are entitled to see what your surgeon billed, and what your insurance company paid.

[mrskrzyz 1]

Thanks so much for your time and putting things in perspective for me. I, of course, hadn't looked at it from that point of view.

I did check my insurance papers and it was approved for both procedures and had codes for both procedures.

I guess we will wait and see how the billing part happens. I usually get the "eob" letter a week or two after each procedure.

Thanks again.

[Candle 11]

I have a consult scheduled with you in March, Dr Schulman. I am so excited!! I've only had one other consult so far and I don't feel the doctor was for me.

Just wanted you to know how sweet and helpful your receptionist is on the phone as well!

[Dr. Schulman 2]

I have a consult scheduled with you in March, Dr Schulman. I am so excited!! I've only had one other consult so far and I don't feel the doctor was for me.

Just wanted you to know how sweet and helpful your receptionist is on the phone as well!

I look foward to seeing you soon. In addition to choosing a surgeon who is "qualified", it is also important to find one that feels "right". Thanks for the kind words about my office staff.... I will pass along the compliment. The staff is an important part as well because many patients spend just as much (if not more) time interacting with the staff as compared with the surgeon.

[quennee 0]

I have a ques regarding my incision. I am 4 weeks out and I have 2 spots about the size of a nickle on each side of my groin towards my hip that are not healing great. They appear to be a bit yellowish (kinda like puss) but I am on clendamycin 3 times daily form my reg dr. I have a few issues. Is it normal for some areas to heal so quick while others drag? My back looks as if I had the surgery a year ago. Also what should I do other than keeping the area dry, using bentadine to cleanse,a nd the antibitoics. I will probably go see my reg dr next Tues. I am just curious on what else I could be doing to make this area heal quicker? Thanks

[Shalee04 7]

Dr Schulman,

I had a Anchor TT on Oct 23, 2008. I had a large wound seperation, skin necrosis. It has just finally healed after almost 4 months. But it didn't heal smoothly and I will need a revision done to correct this. My question is. WHAT are the chances of having the same problem again??? I see my Ps today to talk about this, but was wondering what your opinion was also. I know it is not as extensive at all as the first surgery, but I am still scared to death of this happening again. But I cannot live with what the healed area looks like...

Thanks,

Kelly

[Dr. Schulman 2]

I have a ques regarding my incision. I am 4 weeks out and I have 2 spots about the size of a nickle on each side of my groin towards my hip that are not healing great. They appear to be a bit yellowish (kinda like puss) but I am on clendamycin 3 times daily form my reg dr. I have a few issues. Is it normal for some areas to heal so quick while others drag? My back looks as if I had the surgery a year ago. Also what should I do other than keeping the area dry, using bentadine to cleanse,a nd the antibitoics. I will probably go see my reg dr next Tues. I am just curious on what else I could be doing to make this area heal quicker? Thanks

Small areas that hela more slowly is quite common - in fact, about 25% of people have these "nuisance" complications. The best way to make it heal quicker is to keep your nutrition maximized, particularly the Protein. I would avoid using betadine unless it is very very dilute - 1/10 betadine to 9/10 Water. Betadine can be toxic to healing tissue and actually slow the healing process. Same thing with peroxide. The areas may be a reaction to some sutures underneath the area.