Ask Dr. Schulman...

[Sue Magoo 71]

Hi Dr. Schulman:

I have a few questions concerning panniculectomy versus Tummy Tuck.

Thank you for sharing your expertise with all of us on this website.

I've gone from 324 (April 2007) to 188 (now), and hope to get to 159 by the end of the year so that I will have normal BMI. I have alot of loose skin, especially in my lower abdominal area.

Can you please explain the difference between a panniculectomy and a tummy tuck?

My insurance will cover a panniculectomy if I can show a history of rashes, etc. If I were to get them to approve a panniculectomy and I opted to get the tummy tuck does insurance usually cover a significant part of the cost of the tummy tuck because it takes care of the pannus?

Please let me know. I'm in Massachusetts and I was told to think about $10k for a tummy tuck. I was also told that I should wait a few months after being at goal to get a tummy tuck. Do you agree with this wait?

I look forward to hearing your answers.

Thanks.

Sue

[Dr. Schulman 2]

Hi Dr. Schulman:

I have a few questions concerning panniculectomy versus Tummy Tuck.

Thank you for sharing your expertise with all of us on this website.

I've gone from 324 (April 2007) to 188 (now), and hope to get to 159 by the end of the year so that I will have normal BMI. I have alot of loose skin, especially in my lower abdominal area.

Can you please explain the difference between a panniculectomy and a tummy tuck?

My insurance will cover a panniculectomy if I can show a history of rashes, etc. If I were to get them to approve a panniculectomy and I opted to get the tummy tuck does insurance usually cover a significant part of the cost of the tummy tuck because it takes care of the pannus?

Please let me know. I'm in Massachusetts and I was told to think about $10k for a tummy tuck. I was also told that I should wait a few months after being at goal to get a tummy tuck. Do you agree with this wait?

I look forward to hearing your answers.

Thanks.

Sue

A panni only removes the skin that is below the belly button and hanging down. It does not move the belly button or does not tighten the muscle.

A TT removes the skin, moves the belly button, and most importantly tightens the muscle. A TT is ALWAYS COSMETIC.

Insurance may reimburse for a panni, because of rashes, pain, etc. But insutrance recognizes that a TT is above and beyond what is medically necessary.

If insurance will cover a panni, but you opt to have a full TT because the cosmetic outcome is much better, you will be responsible for the difference. Obviously, price varies between surgeons and regions, but the panni reimbursement may be about 25% of the cost of a full TT.

I think it is a good idea to wait 3-6 months after reaching goal before having a TT. This will allow your skin to "shrink" as much as possible. As I have stated here many times, some people may be candidates for a panni even before they are at goal if the lose skin is causing significant problems.

[Lap_dancer 8]

Second update:

I have an appt. next Wednesday for a consultation with a PS. I am familiar with his breast work reconstruction (excellent) and I was told by the office manager he has done 'about 30 gastric patients'. We shall see if it's a match between myself and him.

Dr. thank you again for you direction.

[Lap_dancer 8]

Question for our doctor. What would be beneficial for me to bring to the consultation? Would he need to see my band card to show where the port is (has photo)? I'm certain this might sound a bit silly but as an educator I'm always aiming to educate as much as possible to facilitate the process.

Thank you Dr. Schulman.

[Dr. Schulman 2]

Question for our doctor. What would be beneficial for me to bring to the consultation? Would he need to see my band card to show where the port is (has photo)? I'm certain this might sound a bit silly but as an educator I'm always aiming to educate as much as possible to facilitate the process.

Thank you Dr. Schulman.

I don't think that he needs to see the card. He should be able to feel where the port is. I fyou have any documentation about rashes, back pain, etc. you should bring it with you because he will need it to include in a letter to your insurance company. Good luck.

[kareyquilts 1]

Dr. Schulman: I believe in one of your posts you made a negative statement about laser Lipo. I'm wondering why? I believe I read something to the effect that the body does not absorb the melted fat, as previously thought and so the procedure is not very effective. If a plastic surgeon uses smart lipo and sucks the fat out (can't remember the term, brain cramp), can the procedure be effective? I just ask, because I have some upper abodmen fat that I would like to have lipoed and the hype is that the smart lipo also tightens this skin. My Tummy Tuck is great, but I still have loose skin and a little fat on the upper abdomen. I am starting to loose weight again and hitting my exercise and diet hard. After I loose the last 20 pounds I know that the loose skin will be a little looser, the upper ab fat might be gone (who knows!), I really hate this area of my body always have. I suggested an anchor incision when I had my tt, but the doc didn't think it was necessary. Not sure how to proceed. Also, in David Hurwitz book on The Total Body Lift, he mentions that he puts his patients on the HCG diet before surgery to lose 20 to 50 pounds quickly, because it targets Type 3 fat and the rapid weight loss of this system does not cause as much loose skin. Have you heard of this? Do you think it is safe? Love your comments and insights.

[Dr. Schulman 2]

Dr. Schulman: I believe in one of your posts you made a negative statement about laser Lipo. I'm wondering why? I believe I read something to the effect that the body does not absorb the melted fat, as previously thought and so the procedure is not very effective. If a plastic surgeon uses smart lipo and sucks the fat out (can't remember the term, brain cramp), can the procedure be effective? I just ask, because I have some upper abodmen fat that I would like to have lipoed and the hype is that the smart lipo also tightens this skin. My Tummy Tuck is great, but I still have loose skin and a little fat on the upper abdomen. I am starting to loose weight again and hitting my exercise and diet hard. After I loose the last 20 pounds I know that the loose skin will be a little looser, the upper ab fat might be gone (who knows!), I really hate this area of my body always have. I suggested an anchor incision when I had my tt, but the doc didn't think it was necessary. Not sure how to proceed. Also, in David Hurwitz book on The Total Body Lift, he mentions that he puts his patients on the HCG diet before surgery to lose 20 to 50 pounds quickly, because it targets Type 3 fat and the rapid weight loss of this system does not cause as much loose skin. Have you heard of this? Do you think it is safe? Love your comments and insights.

Laser lipo (aka "smart lipo") was very very popular about 1 year to 6 months ago. The theory is that it was minimally invasive and the skin tightened. The problem is that it is not "as advertised." The fat still needs to be sucked out, and the skin does not tighten as much as the proponents claim. Basically, it is no different (in my hands) than well performed, careful traditional liposuction. There was a large "gimmick" factor and the company put tons of money into advertising directly to consumers (as opposed to the doctors). It is an incredible example of the power of marketing overriding the power of evicence-based medicine. Most plastic surgeons never started to use laser lipo because they get great results with regular liposuction. The down-and-dirty truth is that the people using laser lipo were the family docs, gynecologists, dermatologists, and podiatrists!

As you notice, you hear much less about laser lipo now.....makes you wonder, huh? Believe me, i am all for technological advances, but I am not going to jump on the latest fad until it can be proven safe, and more effective than what I already use. It is only fair to my patients.

Regarding the HCG diet, I can't comment too much on it because I only know a little about it. There may be something to it, but the data is not strong enough yet. I get concerned of the side effects. I am also not convinced that the rapid weight loss does not lead to as much loose skin.....seems to defy logic. Either way, I know Dennis and he is an excellent surgeon and physician, so he may be onto something. Time will tell.

You had to get me all worked up over laser lipo, didn't you? I should also mention that I do research for several laser companies, so I am definitely openminded about this stuff. I just haven't seen anything that can give a better result than traditional liposuction. And when they say you will be back to work teh day after laser lipo.......yeah, right!

[Lap_dancer 8]

I don't think that he needs to see the card. He should be able to feel where the port is. I fyou have any documentation about rashes, back pain, etc. you should bring it with you because he will need it to include in a letter to your insurance company. Good luck.

Dr. Schulman what about if you can look at the area and see scaring, that is, the skin is much shinier on the surface, reddish to darker in shade to deep red along the underside of the skin at the crease. The hair follicals must have been damaged from persistant friction because you can clearly see where the growth of hair ends. It's my thought that any trained eye can look and see the results of years of infection, irritation and so forth. I am looking at it like scaring from a burn. Same difference. You would see some pattern in a first, second or third degree burn by the damage left. Does that make sense? There is no doubt looking at my skin the damage that's been done. As for my breasts, they fall to almost my navel. So very disproportioned to my chest that it's almost obtuse to look at.

[kareyquilts 1]

Dr. Schulman: Glad you had an opinion on SmartLipo! Thanks for your honesty and forthrightness. I do appreciate it. I will wait till I lose the last 20 and decide if I'll do the back side and maybe get some Lipo or revision then if I need it. I've got an appointment with a doc to perhaps do the HCG diet, so I'll let you know my experience with it at any rate. Thanks again, what an asset you are to this forum!

[KD8888 0]

Dr. Schulman,

I'm scheduled for a BL and LBL 8/13. I'm starting to worry that I won't have enough weight off before the surgery. I carry most of my weight in my upper stomach area which is significantly reduced, but I still have a little more fat there than in the abdomen. How close to goal do I need to be to get a good result?

If I am not ready in August, I will need to move the surgery to December, but that poses another problem, so I'd really like to be able to be ready in August. I have increased my workouts and I could add a morning walk on the treadmill. Do you have any recommendations regarding caloric intake/restriction with such a surgery coming up?

Thank you for information and suggestions.

[Dr. Schulman 2]

Dr. Schulman,

I'm scheduled for a BL and LBL 8/13. I'm starting to worry that I won't have enough weight off before the surgery. I carry most of my weight in my upper stomach area which is significantly reduced, but I still have a little more fat there than in the abdomen. How close to goal do I need to be to get a good result?

If I am not ready in August, I will need to move the surgery to December, but that poses another problem, so I'd really like to be able to be ready in August. I have increased my workouts and I could add a morning walk on the treadmill. Do you have any recommendations regarding caloric intake/restriction with such a surgery coming up?

Thank you for information and suggestions.

A LBL is the largest of the surgeries. This is one procedure I think should wait to goal (or at leas wait until your weight loss stops). It has a long recovery and is expensive....2 reasons not to want to have to do it again! I am a big advocate of surgery before reaching goal - but only whent he excess skin becomes so problematic that more weight loss would be impossible without surgery. Having a LBL too early will make it very likely that you will have to have a major revision when your weight loss starts again (and yes, it almost always does start again after PS)

There is no trick to losing the extra weight before surgery. Rapid weight loss right before a big operation may place you at increased risk for complications - think about how nutritionally depleted you would be, and your body needs the nutrients to heal - this is why many PS prefer that they band is deflated a week or two before, so that you can eat!

Discuss with your PS, but my thought is that it might be best for you to hold of on the LBL (maybe consider just a panni). You have a lot invested in your weight loss - don't rush the PS....you will have a much better result if you wait until your body is ready. You shouls be ok with the BL. Your PS should give you an honest answer about waiting - reputable PS should think with their head and not the wallet.

more tough love from Dr. S......

[KD8888 0]

I was the only one pushing it. I really thought I'd have the weight off by now, but I was having problems with my band several months ago and had to have an unfill and the weight loss slowed.

I definitely want to be healthy and not put myself at increased risk of complications when I have the surgery, so I needed to hear what you thought. No problem with the tough love here!

Thanks again.

[Dr. Schulman 2]

I was the only one pushing it. I really thought I'd have the weight off by now, but I was having problems with my band several months ago and had to have an unfill and the weight loss slowed.

I definitely want to be healthy and not put myself at increased risk of complications when I have the surgery, so I needed to hear what you thought. No problem with the tough love here!

Thanks again.

As bad as you want to have the surgery now, you will be happy waiting to December - your result will be much better and your risk of complications will be less.

Rapid weight loss right before PS will increase complications - not major life-threatening complications - but smaller, "annoying" complications like wound separation and seromas. It all has to do with nutrition. Your body is already in a state of "malnutrition" from the band itself. This is why it is important to see the nutritionist when you are preparing for PS to test bolood count and Protein level. Multivitamins and high Protein diets will be very helpful for the few weeks before PS.

[Foofy 0]

Dr. S.

We very much appreciate you candor and insight. The whole PS thing is new to many of us, although we can see it looming in our future. It can be hard to sort through what is hype and what is truth on our own. I for one am very appreciative of having such an experienced resource to turn to for input.

Thanks!

[kareyquilts 1]

Dr. Schulman: If Smartlipo doesn't work for tightening the skin, are there any non-surgical procedures that help with loose skin?