Ask Dr. Schulman...

[Dr. Schulman 2]

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.

[ShinerGirl 0]

Hi. I'm a new user/poster to this site and came upon this thread due to the PS I'm continuing with. I apologize in advance for the length of this post. I was banded in 2002 and reached my goal weight within 9 months. I'm now 38. I was relatively "light" compared to some WLS patients (238 lbs. to 150 lbs. at 5' 6") but I still have loose skin issues. Unfortunately (sort of), it seems like I have just enough loose skin in some areas to need something done, but not enough to benefit from many of these procedures relative to the scarring they would leave. I consulted with three plastic surgeons and none of them would do any type of body lift on me. So, I had a TT one year ago (July) that was quite successful, but as expected I still have love handles and jiggle in places that seems more notice-able now that the front abdominal skin was tightened. I am scheduled for a BL and back Lipo next week. My upper abdomen still has some fatty areas (at the bra line in front and on the sides) which hopefully will be rectified with mild lipo and the BL. I may need implants (I'm only a C cup now) down the road, along with an arm lift. So finally, here are my questions. My surgeon (highly regarded) here in CT uses Vaser liposuction often, and since I won't be having skin tightening with this surgery, I'm curious about how well it may contract. I know it will still be looser than I want, but he was hesitant to do any "cutting" without seeing what lipo alone would do. He doesn't want to leave scars when this might work "enough" to make significant improvements. I wanted to see what your opinion was about Vaser, since my understanding is that it's different than SmartLipo, and what you think the chances are for any type of skin contraction after this. Is Vaser still considered tumescent lipo? Also, is an arm lift ever done leaving half a scar and not a full scar to the elbow? I was told it was possible in my case because I don't have that much to take off, but I've never seen any evidence of that "shorter" scar online. It took me a long while to realize that a lot of these procedures seem to need "tweaking" after the initial surgeries and that this will be a longer process than we might realize. It very much is about shedding that skin of our "former" selves and moving on. I'm not sure a lot of people realize that unless they've lived it. So, thank you for all of your thorough information. It has helped me tremendously reading the last 11 pages of posts. If you have any thoughts or suggestions about Vaser vs. anything else, and the abbreviated brachioplasty, please let me know. Thank you again.

Edited August 11, 2008 by ShinerGirl

[Dr. Schulman 2]

Hi. I'm a new user/poster to this site and came upon this thread due to the PS I'm continuing with. I apologize in advance for the length of this post. I was banded in 2002 and reached my goal weight within 9 months. I'm now 38. I was relatively "light" compared to some WLS patients (238 lbs. to 150 lbs. at 5' 6") but I still have loose skin issues. Unfortunately (sort of), it seems like I have just enough loose skin in some areas to need something done, but not enough to benefit from many of these procedures relative to the scarring they would leave. I consulted with three plastic surgeons and none of them would do any type of body lift on me. So, I had a TT one year ago (July) that was quite successful, but as expected I still have love handles and jiggle in places that seems more notice-able now that the front abdominal skin was tightened. I am scheduled for a BL and back Lipo next week. My upper abdomen still has some fatty areas (at the bra line in front and on the sides) which hopefully will be rectified with mild lipo and the BL. I may need implants (I'm only a C cup now) down the road, along with an arm lift. So finally, here are my questions. My surgeon (highly regarded) here in CT uses Vaser liposuction often, and since I won't be having skin tightening with this surgery, I'm curious about how well it may contract. I know it will still be looser than I want, but he was hesitant to do any "cutting" without seeing what lipo alone would do. He doesn't want to leave scars when this might work "enough" to make significant improvements. I wanted to see what your opinion was about Vaser, since my understanding is that it's different than SmartLipo, and what you think the chances are for any type of skin contraction after this. Is Vaser still considered tumescent lipo? Also, is an arm lift ever done leaving half a scar and not a full scar to the elbow? I was told it was possible in my case because I don't have that much to take off, but I've never seen any evidence of that "shorter" scar online. It took me a long while to realize that a lot of these procedures seem to need "tweaking" after the initial surgeries and that this will be a longer process than we might realize. It very much is about shedding that skin of our "former" selves and moving on. I'm not sure a lot of people realize that unless they've lived it. So, thank you for all of your thorough information. It has helped me tremendously reading the last 11 pages of posts. If you have any thoughts or suggestions about Vaser vs. anything else, and the abbreviated brachioplasty, please let me know. Thank you again.

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.

[css95 0]

I am 61 now, 5'4". I was banded 9/10/07 started out at 210 LBS. and I am now 178LBS. I am a very slow loser, but I am not gaining. My goal is 150 LBS. Now, I would like to have a TT, legs, and arms done.

The big one is that I have 36 LL, my dream is to have C cups.

As I mentioned, I am 61 and beginning to wonder about my age?

How close to my goal should I be? I wanted to have my Breast done, but then I want to get a couple things done at one time.

Just need some good advise. Oh, I am in good health, no problems.

What kind of follow up is there? If I travel 2 hours from my Home to have work done, should I expect to go back to the Dr. 4 to 5 times?

Thanks you Dr. Schulman for all you have done for everyone.

[Dr. Schulman 2]

I am 61 now, 5'4". I was banded 9/10/07 started out at 210 LBS. and I am now 178LBS. I am a very slow loser, but I am not gaining. My goal is 150 LBS. Now, I would like to have a TT, legs, and arms done.

The big one is that I have 36 LL, my dream is to have C cups.

As I mentioned, I am 61 and beginning to wonder about my age?

How close to my goal should I be? I wanted to have my Breast done, but then I want to get a couple things done at one time.

Just need some good advise. Oh, I am in good health, no problems.

What kind of follow up is there? If I travel 2 hours from my Home to have work done, should I expect to go back to the Dr. 4 to 5 times?

Thanks you Dr. Schulman for all you have done for everyone.

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!

[ShinerGirl 0]

Thank you, Dr. Schulman, for your quick and detailed response to my Vaser/Brachioplasty questions. I may look you up (I'm in CT, relatively close to NYC) when the time comes for the "short scar" arm procedure. Thanks again.

[targa 0]

Shiner Girl-

I am suprised you feel you need so much revision surgery since you didi not have all that much weight to lose. I am getting banded in a couple of weks and have about 85 lbs to lose, and was really hoping I wouldnt have to do much more than a breast lift.

Have you worked out with weights during your weight loss, and do you feel like that had any effect? I know Dr Schulman says it is part hereditary, part the amout of weight loss and how fast you lose it, and also your age. I also know people who spend alot of time in the sun seem to have saggier skin...just curious on your thoughts on this.

Thanks so much-

Targa

[ShinerGirl 0]

Hi Targa...Well, trust me, I was surprised I had the excess skin as well, given the relatively lesser amount of weight I had to lose. (Isn't it amazing how 90 lbs. is considered "not that much" weight?) I think part of it in my case is that I have always carried most of my weight in my stomach/abdomen, and that I have always been at least overweight since childhood. So by the time I had the band surgery and lost the weight, I was 33, which is still relatively young, but my abdominal skin already had stretch marks and was probably worse for wear than people who haven't been through extremes of weight. As for your questions, I am a pale natural redhead, so I do not and have not ever tanned, because I don't like to sunburn! During the year (actually 9 months) that I was actively losing weight with the band, I did both weight training and used my elliptical machine, for at least an hour a day every day. I thought that would help with toning the skin, and I think it did, but it was evident that I was going to need some cosmetic assistance in some areas. Again, relative to most other WLS patients, I didn't have that much excess skin but it was enough to bother me and affect me emotionally. My main reason for having the TT (and for my BL and Lipo next week) is that I wanted to be more proportionate and have my clothes fit better; after my weight loss it was apparent that I was a much bigger size on top than on the bottom. I was wearing a size 6 or 8 in jeans, to accommodate my larger waist, but the legs/thigh/butt areas of the jeans were falling off of me. Conversely, I was wearing between a 10/12/14 on top for shirts, so finding a dress or professional attire to fit me across the top and bottom sizes was very difficult. Mostly though, I just felt like the excess skin was a symbol of the "old" me and I wanted to not be reminded of that every day...I wanted to look forward, and for once in my life I wanted to have a waist and no rolls. I've never in my life been able to sit down and not have a roll around my waist, from childhood on. So now, even after the TT, I have some excess folds in the waist, abdomen, and axillary (side where the bra line is) areas, which are why I'm having lipo. The TT did a great deal in terms of tightening the skin and the underlying muscles (which were considerably stretched even though I've never had a child), but it seems that a lot of cosmetic procedures that WLS patients have just need some "tweaking" afterward because it's very hard to predict how our skin will respond to the weight loss, and to the cosmetic surgery as well. I will say that there are probably a lot of people who would not have had surgery to correct the amount of excess skin I had; I had enough for three different cosmetic surgeons to tell me certain procedures (like the TT and BL) would make a dramatic change in my appearance, while other areas (arms, legs/thighs) would not benefit me as much and the scarring would not be worth it. A body lift was not an option for me because I didn't have enough excess skin to justify that procedure, but I had enough for some others. I can say that the TT definitely changed my overall shape, and I hope the BL and lipo will have similar results. Even with this additional cosmetic surgery, which I didn't realize I'd need before the band surgery, I'd still have chosen the band since it has given me my life back. Now...you may have a completely different situation than me in terms of excess skin, and you may not require even the breast lift you expect. I truly hope that is the case, but working out consistently and tweaking your diet will certainly give you better results than not doing so. I hope this (wordy!!) explanation helps, and I wish you much luck on your journey.

Edited August 12, 2008 by ShinerGirl

[css95 0]

Dr. Schulman:

From: Just need some good advise:

Thank you so much for getting me an answer so fast. Your answer was very encouraging. I am in So. Ca. and you are in NY. That is why I asked how many follow visits I would need. Could you recommend any PS in So. CA ?

Thanks

CSS95

[Dr. Schulman 2]

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.

[Dr. Schulman 2]

Dr. Schulman:

From: Just need some good advise:

Thank you so much for getting me an answer so fast. Your answer was very encouraging. I am in So. Ca. and you are in NY. That is why I asked how many follow visits I would need. Could you recommend any PS in So. CA ?

Thanks

CSS95

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.

[juliegeraci 7]

Dr. Schulman, I have been through a lot. I am not happy with my Tummy Tuck or thigh lift and spent $20k for it. I met with a new surgeon yesterday that definitely said my surgeon was not skilled enough for a bariatric patient. He would have done an incision down my stomach and bikini line, starting first with lippo 3 month preop. I don't even want to talk about my thigh lift because it is such a disaster. Do you know of any top notch surgeons in the San Francisco bay area? I live 60 miles South of there. Julie

[Dr. Schulman 2]

Dr. Schulman, I have been through a lot. I am not happy with my Tummy Tuck or thigh lift and spent $20k for it. I met with a new surgeon yesterday that definitely said my surgeon was not skilled enough for a bariatric patient. He would have done an incision down my stomach and bikini line, starting first with lippo 3 month preop. I don't even want to talk about my thigh lift because it is such a disaster. Do you know of any top notch surgeons in the San Francisco bay area? I live 60 miles South of there. Julie

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!

[loridee11 519]

Hi Dr.!

I am scheduled for an extended Tummy Tuck in November with a vertical incision (in addition to the horizontal). I have another consult with my Dr. in October and will be asking him this question, but I thought I'd get your thoughts as well.

What type of difference in my overall shape can I expect by adding the vertical incision to my tummy tuck. I'm trying to weigh in my mind if the results will be worth the extra scaring... Would you expect 1/2 inch reduction in circumfrance or more? I know this will change based on each individuals body type, I'm just wondering if there is any general expectation.

For some background, I am 5'11 and weighed 330 at my heaviest. I am down to 202, and hope to be down to 180 by surgery. I carried a lot of weight in my abdomen and have two rolls of excess skin and fat, one above and one below my bellybutton.

I appreciate your thoughts :thumbup:

~Lori

[Dr. Schulman 2]

Hi Dr.!

I am scheduled for an extended Tummy Tuck in November with a vertical incision (in addition to the horizontal). I have another consult with my Dr. in October and will be asking him this question, but I thought I'd get your thoughts as well.

What type of difference in my overall shape can I expect by adding the vertical incision to my tummy tuck. I'm trying to weigh in my mind if the results will be worth the extra scaring... Would you expect 1/2 inch reduction in circumfrance or more? I know this will change based on each individuals body type, I'm just wondering if there is any general expectation.

For some background, I am 5'11 and weighed 330 at my heaviest. I am down to 202, and hope to be down to 180 by surgery. I carried a lot of weight in my abdomen and have two rolls of excess skin and fat, one above and one below my bellybutton.

I appreciate your thoughts

~Lori

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.