Ask Dr. Schulman...

[loridee11 519]

Hi Dr.

I am interested in having several procedures, and am wondering about how many surgeries will be required, and how long I should wait between

each. I am looking at:

Tummy Tuck

Thing lift (probably inner and outer, but definately inner)

Butt lift

Breast lift (I'm currently a DDD, and want to be a D, so maybe reduction)

Armplasty

I appreciate any advice you can give!

~Lori

[Dr. Schulman 2]

Hi Dr.

I am interested in having several procedures, and am wondering about how many surgeries will be required, and how long I should wait between

each. I am looking at:

Tummy Tuck

Thing lift (probably inner and outer, but definately inner)

Butt lift

Breast lift (I'm currently a DDD, and want to be a D, so maybe reduction)

Armplasty

I appreciate any advice you can give!

~Lori

As with most weight loss patients, you have several areas that you want improved. I think you will need 2, possibly 3 surgeries. A good way to start might be with a Lower body lift - this includes a butt lift, outer thigh lift, and tummy tuck. Next an arm lift and breast reduction (lift is part of a reduction) go well together. Experienced plastic surgeons may also perform an inner thigh lift at this time also, or thigs can be split up for a 3rd procedure.

I think that you should wait about 3 months in between, although I have done similar sequences with only 6 weeks in between in very motivated patients. if you are interested in having these procedures done in as few operations as possible, make sure you chose a surgeon who specializes in body contouring after weight loss.

Here are some links to pictures that you may find helpful:

Lower body lift

arm lift (brachioplasty)

inner thigh lift

breast reduction

[Dr. Schulman 2]

Hi Dr Schulman

I had an armlift in March this year. The scars are at the back of my arms (I wasnt given any reason for this but had expected them to be on the inside of the arms) and the arms themselves are not as slim as I would have liked given the extent of the scarring. The measurement pre-op was 15 inches and post op is 13 inches. The scars are positioned at the back but close to the inner side. In such circumstances where there is still a significant amount of excess skin, do you think a revision op might be possible to remove the excess and reposition the scar on the inner side of the arm so that it's not immediately visible from the back?

Thanks for your advice.

Ellen

Generally, scars after armlifts are kept along the inside of the arm so that with your arms at rest at your side, the scar is invisible from the front, from the back, and from the side. The scar would only be visible when the armis lifted.

I am nto sure why your scars are in the position that they are. You should not place too much emphasis on the measurement of your arms. It can be very deceptive. The most important thing is appearance of your arms and that they are in proportion to the rest of your body.

It is very possible that a revision would help to remove more tissue (especially when combined with liposuction) and the scar can be repostioned to a more aesthetically pleasing location 9along the inner aspect of the arm).

Here is a picture of a typical armlift.

[Frangipani 1]

Hi Dr. Schulman,

Thank you for the info on buttocks augmentation. I am having some surgery in a few weeks, but it won't involve the buttocks at this time. However, I am planning to have the buttocks lift ASAP after my first surgery, so now you have me thinking about some issues (i.e., the possibility of needing augmentation along with the lift), that I hadn't thought about before.

The procedure you did on your patient looks good, I like the way her skin is so smooth and youthful in the after photos. I have never really thought about PS in terms of taking years off the "backside," but you managed to do this with your patient.

[ellen 0]

Dr Schulman

Many thanks for your advice re armlift revision above.

Ellen

[kareyquilts 1]

Dr. Schulman: The autologous buttock augmentation looks very interesting. Is it hard to decide how large the buttocks should be. I would imagine part of the size would be determined by the amount of fat that could be grafted (not sure that's the right term). I already have a very small and somewhat flat bottom. I've had a Tummy Tuck and Lipo to the flanks. The back side would be next. How can you tell if you are a candidate for this procedure?

[Dr. Schulman 2]

Dr. Schulman: The autologous buttock augmentation looks very interesting. Is it hard to decide how large the buttocks should be. I would imagine part of the size would be determined by the amount of fat that could be grafted (not sure that's the right term). I already have a very small and somewhat flat bottom. I've had a Tummy Tuck and Lipo to the flanks. The back side would be next. How can you tell if you are a candidate for this procedure?

I use this technique more for restoring a normal buttock volume....not really for increasing the size. As you know, when you lose weight, you lose fat in the buttock as well. After a LBL, the butt get even flatter.

Try this out.....turn around, grab the lose skin just above your buttock, and lift up as much as possible - this will simulate the LBL. Now, look in the mirror and see if your butt gets even flatter. I bet it will. If it does, then you are a candidate for an augmentation at the same time as a LBL.

[kareyquilts 1]

Dr. Schulman: Your enthusiasm for what you do is really admirable. Thanks for the great pictures and equally good explanations. I'm really trying to decide if the results will be worth the pain and expense. This helps, but I'm still not sure about the buttock's volume. I guess I'm a little concerned that it might make me look bigger and flatter would look thinner. Your pictures make me think that some round is normal and probably pleasing. Just not sure. Does the belt lipectomy decrease size overall and the augmentation just add some roundess and not a lot of size? It's hard to grasp the proportions from the pictures.

[gachic 0]

Dr. Schulman,

I have decided to have the lap band procedure. However; about 2 months agao I had a large ventral hernia repaired (no mesh was used), and some liposuction. I have looked at where the incisions go, and should I be worried about damaging the abdominal wall again? Is there an amount of time I should wait? Also, I've always since I was a teenager at least had that "spare tire" so to speak around my hips. One Plastic Surgeon told me that it wouldn't go away, no matter how much weight I lost. Is this true? And why? I'm not a big surgery fan. Thanks for your time.

[BeckyinTexas 3]

Dr. Schulman....I've lost nearly 300 pounds and as you would know, I need a pannicolectomy. I visited a plastic surgeon in Dallas and we sent in all the information to my insurance company but I was denied. They said it was cosmetic rather than medically necessary. I'd hate to see the poor sould they considered medical. I have constant rashes, infections and since my denial, I've been dealing with depression and I've never had that before. At one point, I thought all my hard work was for nothing when looking at myself disgusted me. My question to you is this....what is your experience with patients that appeal the original decision. I don't have anything documents as far as the rashes/infections go because I work for a county that provides us a PA and I just go next door and ask someone to recommend something to use. I wish I had stock in Gold Bond because I use a large can a week. Do you have any suggestions for me? I've got to snap out of the funk I've been in because I know I should just be thankful to have lost so much weight but I don't think I've ever been this discouraged. Thanks for any help you might give me.

[Dr. Schulman 2]

Dr. Schulman: Your enthusiasm for what you do is really admirable. Thanks for the great pictures and equally good explanations. I'm really trying to decide if the results will be worth the pain and expense. This helps, but I'm still not sure about the buttock's volume. I guess I'm a little concerned that it might make me look bigger and flatter would look thinner. Your pictures make me think that some round is normal and probably pleasing. Just not sure. Does the belt lipectomy decrease size overall and the augmentation just add some roundess and not a lot of size? It's hard to grasp the proportions from the pictures.

I think you have the idea....the buttock augmentation (when done with a LBL) just adds volume back that is lost during the procedure. It will restore "normal" proportions, and is not intended to give you a "J-Lo" butt. If you look at the pictures and think to yourself, "the butt is not that big," than that is the result I was going for!

[Dr. Schulman 2]

Dr. Schulman,

I have decided to have the lap band procedure. However; about 2 months agao I had a large ventral hernia repaired (no mesh was used), and some liposuction. I have looked at where the incisions go, and should I be worried about damaging the abdominal wall again? Is there an amount of time I should wait? Also, I've always since I was a teenager at least had that "spare tire" so to speak around my hips. One Plastic Surgeon told me that it wouldn't go away, no matter how much weight I lost. Is this true? And why? I'm not a big surgery fan. Thanks for your time.

There should not be any risk of damaging the abdominal wall. You may have to wait a few more months for things to heal, though, before having the band placed.

I suspect that the "spare tire" will decrease with weight loss, but the excess skin will remain. It probably has more to do with your body shape, and not necessarily the weight. Some women store most of the fat in the hips and thighs. This is what we refer to as a "pear shape" - as opposed to men who store the fat in the abdomen (the "apple" shape). Usually, this shape remains, even after weight loss. Luckily, there are many experienced plastic surgeons who can help you with this.

Good luck on your weight loss

[Dr. Schulman 2]

Dr. Schulman....I've lost nearly 300 pounds and as you would know, I need a pannicolectomy. I visited a plastic surgeon in Dallas and we sent in all the information to my insurance company but I was denied. They said it was cosmetic rather than medically necessary. I'd hate to see the poor sould they considered medical. I have constant rashes, infections and since my denial, I've been dealing with depression and I've never had that before. At one point, I thought all my hard work was for nothing when looking at myself disgusted me. My question to you is this....what is your experience with patients that appeal the original decision. I don't have anything documents as far as the rashes/infections go because I work for a county that provides us a PA and I just go next door and ask someone to recommend something to use. I wish I had stock in Gold Bond because I use a large can a week. Do you have any suggestions for me? I've got to snap out of the funk I've been in because I know I should just be thankful to have lost so much weight but I don't think I've ever been this discouraged. Thanks for any help you might give me.

The insurance companies have goten very tough, unfortunately. Generally, they require that the the pannus hangs to the level of the pubis (your PS should take pictures and send it in to them). Also, they require taht you have rashes, not responsive to topical treatments for a period of at least 6 months. You should get a prescription for an anti-fungal cream or powder. It should be a prescription (even if you chose to not use it and only use your gold bond) because your pharmacy and insurance company will have a record that this was prescribed. The only other thing to try is to see a chiropractor that will document back pain and radiographic changes in your spin consistent with the weight of the pannus.

Try the appeal. Sometimes it works. If this fails, and you cannot afford to self-pay, you might want to consider finding plastic surgery residency programs in your area - they perform cosmetic surgery at greatly reduced prices (likely under 2,000 -3,000 for this procedure). Make a call to the local teaching hospitals (UTSW, BAylor, UTSA, etc.)

[kareyquilts 1]

Becky: My heart goes out to you! I know how a hanging pannus can make you feel that you are still fat. Don't get depressed, you are tough or you couldn't have lost so much weight. Appeal to the insurance company and document like Dr. Schulman recommended. Check out the teaching schools, that sounds like a great suggestion. Personally, I would beg, borrow or steal (not really, but you get the idea), the money to get the surgery. Don't let anyone intimidate you and make you think that it's only cosmetic. This is your life and believe me, getting the pannus off will change the quality of your life. When I had my abdomiplasty and breast lift, I could finally see the results of all my hard work. I didn't look in the mirror and see hanging flesh and still feel fat. I want to finish the process with some other procedures, but I can't tell you how much better I feel about myself. Fight for this!

[BRANDYK 0]

Dr Schulman,

I have surgery scheduled in January to have a breast lift and a "bra roll" lift, along with some Lipo on my neck. I was also wondering if there's anything that can be done about the loose skin on my back that sits above my waist. Can that be removed also? I don't need a Tummy Tuck, my stomach and waist are fine, it's just everything above them that's loose and flabby.