The Complete Guide to LAP-BAND Surgery

TIME TO THROW OUT SOME OLD MYTHS

It's time to throw out some old myths about the adjustable gastric band, but before we start flinging those myths around, let's all agree on what a myth is.

The traditional definition is that a myth is an ancient story of unverifiable, supposedly historical events. A myth expresses the world view of a people or explains a practice, belief, or natural phenomenon. For example, the Greek god Zeus had powers over lightning and storms, and could make a storm to show his anger.

If you think myths are dry stuff found only in schoolbooks, think again. They surround just about every aspect of our lives, and travel much faster now, in the age of technology, than they did in the dusty old days of ancient Greece and Rome. They're a way for us to make sense of a chaotic world, both past, present and future. They affect thoughts, beliefs, emotions and assumptions in our everyday lives, coming alive in our minds as we, and the people around us, seem to act them out.

Some myths are helpful because they give us a shared sense of security and express our fundamental values and beliefs, but some myths are just plain wrong and can be harmful to us and to others. A good example is the myth that having weight loss surgery is taking the easy way out. Every time I hear that one repeated, I want to laugh and scream at the same time. If you're a post-op, you know why. Weight loss is hard no matter how you do it (surgery, diet pills, prayer, magic cleanses, and so on). On the other hand, WLS is supposed to be easy, compared to the dozens or hundreds of weight loss attempts in our past. Why on earth would I put myself through a major surgery if it wasn't going to help me lose weight and keep it off?

Now that we've shared a little laugh (or scream) over a WLS myth we can all agree upon, let's test out some band myths whose validity may not be as clear. This kind of examination can be uncomfortable, but believing in a falsehood is almost guaranteed to make your WLS journey bumpier than it needs to be.

Let's start with the myths that are easiest to digest and end with the ones that can be tougher for a bandster to swallow.

#1 - THE BAND IS THE LEAST INVASIVE WLS PROCEDURE

I believed this one at first, mainly because I knew little about the other WLS procedures back in 2007. It's still a widely-circulated myth, one that even my surgeon's well-intentioned dietitian endorses. So, what's the truth according to Jean? Face it: any surgery done on an anesthetized patient, during which a surgeon cuts into the belly in several places, does some dissection (more cutting) and suturing (stitching) of the internal anatomy, and implants a medical device (the dreaded "foreign object"), is invasive. It is true that band placement generally involves less internal dissection and suturing than other weight loss surgeries, but neither is it on the same level medically as having your teeth cleaned. So while the invasiveness of a surgery is worth considering, you do yourself a disservice if you let that override other considerations. A bariatric surgery might last 45-60 minutes, with recovery lasting a week or so, but its effect on your health and lifestyle last a lifetime. Or I sure hope it does.

Some people associate invasiveness with irreversibility. Although the band is meant to stay put once clamped to your stomach, it can indeed be removed if medically necessary. Gastric bypass (RNY) surgery can also be reversed, while the sleeve (VSG) cannot and only the "switch" (malabsorptive feature) of the duodenal switch (DS) can be reversed. Removal or reversal is not as easy as operating on a "virgin belly" (as my surgeon so colorfully puts it), so it's important to weigh the benefits against the risks of reversal or revision surgery.

#2 - BAND WEIGHT LOSS TAKES TOO MUCH WORK

Aside from the desire for instant and effortless weight loss (which is a fairy tale if I ever heard one) that so many obese people share (me among them), this is a myth that often turns people away from the band and towards other WLS procedures. While this myth may be true in the first 12-18 months after surgery, eventually everyone ends up in the same boat, rowing hard against the powerful tide of obesity.

Weight loss and weight maintenance is hard no matter how you achieve it. A dietitian who spoke at a band support group meeting I attended a few years ago said that while band patients must change their lifestyle immediately to succeed, every WLS patient must do that sooner or later. It's a pay-me-now or pay-me-later deal. You can slice it, dice it, sauté it and serve it on your grandmother's best china. However you serve it, weight loss and maintenance is a lifetime project because obesity is a chronic disease with no cure. No matter how successful we are as new post-ops, all of us must face the possibility of regain. That's why I cringe when someone proudly crows, "XXX pounds gone forever!"

#3 - THE BAND'S SLOWER WEIGHT LOSS PREVENTS SAGGING SKIN

This is a fairy tale. According to several plastic surgeons I've heard speak on the subject. The effect of weight loss on skin depends mostly on your genetics and your age (because skin loses elasticity as we age). Other factors can be how obese you were, how long you were obese, how you carried your weight, and how much (and how) you exercise as you lose weight.

I've heard women say that they'd rather be obese than have sagging or excess skin. To my mind, that's a sad statement, because I'd rather have sagging or excess skin (as long as it didn't interfere with my ambulation or activities) than excess weight. Don't get me wrong: I loathe the excess flab on my midsection (whose nickname is "The Danish Pastry") and I'm not thrilled about my batwings, throat wattles, or anything else that's happened to my skin in the past few years (during which I've undergone the double-whammy of weight loss and the fast approach of my 60's). On the other hand, I think I look pretty good for a woman my age, especially when I conceal my figure flaws in flattering clothing which, I might add, no longer needs to be purchased at Lane Giant.

#4 - TO LOSE WEIGHT, YOU HAVE TO FIND YOUR SWEET SPOT

I used to wonder how the Sweet Spot Myth could survive in the face of so much clinical evidence against it, but last year I heard the "you gotta find your sweet spot" claim uttered by a bariatric dietitian, so apparently this is a myth being validated by medical professionals who ought to know better.

Instead of the sweet spot, Allergan (the first to introduce the band in the USA) uses a zone chart to illustrate band restriction, with not enough restriction in the yellow zone, good restriction in the green zone, and too much restriction in the red zone. In other words, restriction happens in a range of experience, not at a single static point. That experience changes over time as we lose weight, deal with ordinary processes such as hormonal fluctuations, hydration changes, stress, medications, time of day, and so on. It's also affected by our food choices (solid vs soft/liquid food).

In my banded days, I traveled through and around a sweet spot many times. It might last for 30 minutes, 3 days, 3 weeks, but it never stayed exactly the same, and yet I still lost weight! I don't actually want to stay exactly the same for the rest of my life (throat wattles notwithstanding). As any Parkinson's disease patient will tell you (if they're able to speak), a body that gets stuck in time is a very big problem (and with my luck, I'd get stuck in the worst sinus infection or case of the flu of my life). Some people who are very sensitive to their band and its fills find sudden or unexpected changes in restriction to be very, very frustrating, and I wouldn't wish that on anyone, either.

To read more about the sweet spot, click here to go to an article, The Elusive Sweet Spot.

#5 - NO SIDE EFFECTS MEAN MY BAND ISN'T WORKING

Equating side effects with a properly working band is very common, and very harmful. The two most significant signs of the band's proper functioning are (1) early satiety and (2) prolonged satiety. Those signs are rarely expressed in large, bold, uppercase letters, such as

Those signs won't be accompanied by clanging bells or flashing lights, either. In fact, the less noise and distraction (such as "Why don't I have stuck episodes?"), the more likely you are to be able to recognize early and prolonged satiety.

Before I tell you why the no side effects = broken band worry is a sign of mythical thinking, let's make sure we agree on the definition of a side effect, and how that relates to complications. A side effect is an unintentional or unwanted effect of a medical treatment, and it's usually exceeded (or at least balanced) by the benefits (the intentional, wanted effects) of that treatment. For example, antibiotics can cause diarrhea. That's an unpleasant side effect, but an untreated infection can have far worse consequences for the patient. Side effects can often be managed by tweaking or changing the treatment, and they are rarely worse than the original condition.

A complication, on the other hand, is a more acute, serious consequence of a medical treatment, and usually needs a more aggressive approach, including surgery to fix the problem. Now let's go back to the antibiotic example. An allergic, anaphylactic reaction to the antibiotic can be fatal without prompt medical treatment. That's a complication, and it's far worse than the original condition.

So in the context of all that, it seems strange to me when bandsters long for side effects like regurgitation (PB's), stuck episodes, and sliming. Instead of looking for more subtle clues from their bodies (like early and prolonged satiety), they go looking for problems, and worse than that, they tend to "test" their band with foolish eating and/or overeating, hoping to provoke a side effect that will signal to them that they really do have a band in there. One of the many problems with that approach is that it can also provoke a complication. And that brings us to the final myth in today's article:

#6 - THE MORE FILL, THE BETTER

I've heard bariatric surgeons comment that some band patients seem

to be addicted to fills. I can identify with that because I had a good relationship with my band surgeon who not only administered my fills but gave me a lot of encouragement as well as answers to my many questions. I left each fill appointment with a renewed sense of commitment and hope. How can you not get hooked on something good like that?

The problem with equating fills with weight loss success is that more fill is not always better. In fact, too much fill (which varies from one patient to the next, and also varies in a single patient as time goes on and the patient's body keeps changing) can be downright dangerous. An overfilled band, and the side effects it causes (see #5 above), can lead to a complication like a band slip, esophageal dilation, or stomach dilation. While complications can come out of nowhere, most bariatric surgeons agree that too much saline in the band puts too much pressure on the stomach. Eventually something's got to give. That's often hastened by the patient's efforts to eat around the problem, and it is absolutely not a guarantee of weight loss. I gained weight several times because of what's called Soft Calorie Syndrome. My band was too tight and I was dealing with it by consuming mostly soft and liquid calories that offered little or no satiety.

The human body is an incredible organism, capable of amazing feats of growth and healing that we take mostly for granted, but it's not endlessly forgiving. Too much fill in your band, too many eating problems, too much inflammation and irritation in the upper GI tract, can compromise your body's ability to recover from a complication like a band slip. Sometimes a complication can be treated conservatively, with an unfill and rest period, but sometimes it requires a surgical fix, including removal of the band. And after all you've gone through to get that band wrapped around your stomach, shouldn't you be doing your utmost to treat it (and your body) with respect?

Finally, the fill myth can cause us to overlook a very important guest at your WLS party….you. If you are going to succeed with your band, lose weight and keep it off and keep that band safe and sound inside you, sooner or later you will have to take personal responsibility for your success. Expecting your band alone to carry you to your goal weight is like expecting your car to safely deliver your child to school without anybody in the driver's seat. And I sure hope that you are a very important person in your life!

Related: How does a gastric band REALLY work?

I have found that sadly there are a lot of misconceptions around gastric bands. Firstly, there is a misconception that the gastric band creates a small stomach that must be 'filled' to feel full. There is also a misconception that a tighter band will result in more weight loss and that the vomitting or regurgitation caused by a tight gastric band is 'normal'. Another misconception is that you shouldn't be able to eat certain foods with a gastric band.

Let's get back to basics to understand how a gastric band should work. A gastric band is a silicone device placed around the upper part of the stomach. It was once believed that the gastric band created a new, smaller stomach above the band, where food would sit before passing into the lower, larger stomach. Recent studies at the Centre for Obesity Research and Education (CORE) in Melbourne have shown this to be incorrect.

The gastric band actually creates a 'funnel' into the larger stomach and exerts pressure on the stomach. Adjusting the gastric band can vary this pressure. The band has an access point called a port, which is stitched to your abdominal muscle deep under the skin. You can usually tell where the port may be as it is likely to sit somewhere under your biggest scar. Your surgeon or weight loss GP uses the port to adjust your gastric band and vary the pressure it places on the stomach. They can inject or remove saline (a salty water) solution via the port to make your band tighter or looser.

When food is eaten our oesophagus, or food pipe, squeezes bites of food down towards the band. Once food reaches the band, contractions of the oesophagus, called peristalsis, will squeeze well-chewed food past the band. In a person with a well-adjusted band, it can take between two to six squeezes of the oesophagus to get a bite of food across the band. One study suggests this process takes at least a minute.

There are nerves in the stomach that detect when our stomach is stretching, and send a message to our brain that we have had enough to eat. One particular nerve involved in controlling our stomach is called the vagus nerve. With a gastric band sitting around the stomach this squeezes the vagus nerve all the time, and more so when you are eating.

The squeezing process triggers a signal to the brain that you are satisfied, or no longer hungry. This means you feel satisfied on a smaller amount of food than you would have prior to surgery. The constant pressure of the band on the stomach also helps you to feel satisfied for a longer period of time, reducing hunger throughout the day.

Feeling satisfied is different to feeling 'full'. Feeling 'full' means you have eaten to excess. It may indicate food is sitting above the band, either due to eating too quickly, eating large pieces of food or not chewing food well enough. Try to stop eating when you feel satisfied or no longer hungry, rather than full.

Each bite of food must be small and well chewed. An empty, or uninflated band has an opening the size of a twenty-cent piece. A fully inflated band has an opening the size of a five-cent piece. Most people will have their band adjusted somewhere between the two sizes. If you cut food into the size of a five-cent piece size and chew it well, it is more likely to pass comfortably through the band.

Eating slowly also helps you to eat comfortably. In theory, you should aim to wait a minute between each mouthful of food, however it is not practical to time every mouthful. It is practical to put your cutlery down between mouthfuls and wait until you have swallowed before cutting the next piece of food ready to eat. People with a gastric band who eat quickly, describe a feeling of discomfort in their oesophagus, like a 'traffic jam'. Eating slowly will help avoid this.

I hope this clarifies how a gastric band works and what you should experience. If your band is not acting like it should, please follow up with your support team.

Related: All about the Lap-Band

History of the Lap-Band

The band has a pretty long history, dating back to 1983 when a Ukrainian-born surgeon named Dr. Lubomyr Kuzmak used a non-adjustable band on his obese patients. He developed an adjustable band and began to use it in 1986. He and other surgeons continued to use the gastric band on obese patients and carefully record their results. These are some more key events in the development of the current lap-band.

• By 1991, enough progress had been made so that most gastric banding surgeries were laparoscopic instead of open. The adjustable gastric band became known as the laparoscopic adjustable gastric band, or lap-band.
• In 1994, the First International Workshop on laparoscopic banding occurred in Europe as experienced surgeons demonstrated their new techniques.
• In 2001, the Food and Drug Administration (FDA) approved the lap-band as a treatment for morbid obesity, or a BMI over 40, and for individuals with a BMI over 35 and obesity-related health conditions.
• In 2004, the lap-band VG replaced the original lap-band system. It had a bigger fill volume and could be filled all the way around instead of just three-quarters of the way.
• In 2007, the lap-band AP (Advanced Platform) system came out. It's the current lap-band model and it comes in two sizes. Your surgeon will determine which size is best for you.

How the Lap-Band Works

Your stomach is pouch with a J-like shape. The gastric band goes around the narrower, upper portion of your stomach to create a small pouch known as a stoma. The remainder of your stomach, the larger pouch, is below the gastric band. The stoma has a volume of only 15 percent of your original stomach size. Food that you eat goes into the stoma and is held there for a while, above the gastric band, because the band slows down the emptying of food from the stoma to the rest of your pouch. Since the stoma is so small compared to your original stomach, you feel more full after you've only eaten a small amount of food - enough to fill the stoma - instead of needing a huge meal like you did before getting the band.

One of the most important things to remember when you're considering the lap-band or any other weight loss surgery is that the surgery is only a tool to help you. You will still need to be very careful with your diet if you are going to be successful in losing weight and keeping it off. The lap-band will not cause you to lose weight if you choose high-calorie foods, consistently serve yourself large portions, snack too much or drink liquids with calories.

The Surgical Procedure

Now, most lap-band operations are laparoscopic. They require smaller incisions and are safer and easier than traditional open surgeries. The following medical personnel are likely to be in the operating room during your procedure.

• Surgeon who is the leader and who directs the laparoscopic tools in your abdomen
• Anesthesiologist to administer and monitor anesthetics
• Circulator who plays a supportive role by handing instruments to the surgeon and double-checking procedures

Details of the Lap-Band

The lap-band system has three components.

• adjustable gastric band
• thin connection tubing
• access port

The band inflates and becomes more restrictive when your surgeon fills it with saline solution (a liquid). To do this, your surgeon inserts a syringe into the access port, which rests below your skin next to your belly button. The solution travels through the connection tubing to band. An unfill, or deflation, is the opposite of a fill. Adjustments in the fill volume of your gastric band are normal parts of life with the lap-band, especially within the first few months.

Chapter 3, "All about the Lap-Band," in The BIG Book on the LAP-BAND^® talks about all of this lap-band information. You can see diagrams showing the lap-band and where it sits in your body, and get details on things like the surgical procedure. By the end of the chapter, you'll have a good understanding of what the lap-band is and how it works.

Related: Living with Your Adjustable Gastric Band

You've made a adjustable gastric banding surgery, because you need to improve your overall present and future health. Sounds manageable, shouldn't be too difficult; the results following bariatric surgery, 1 year, 3 years and so on, will be worth it. So, you have the surgery and, for awhile, it seems like magic, weight is coming off slowly but surely and you are working hard to move toward greater health goals day by day. If all goes well, you will have few bumps in the road, right? Well, that's the hope, not always the reality.

I can tell you this; you are not alone on this journey and you will probably experience a good degree of success with your adjustable gastric band even if you are faced with a struggle from time to time. The challenges and rewards of surgery go hand in hand. The challenges of all patients remain virtually the same: how do we combine all the team professionals, support services, along with family and friends, to make this surgery work for you? It may help to look at the big picture for a moment and remind ourselves of the common issues that weight loss surgery patients may be facing along the way.

Here are some common challenges that bariatric patients may encounter at any point in the post-operative journey:

• YOUR HABITS ARE TOUGH TO BREAK: You are human and make mistakes; you have habits and memories of the way food is woven into your life over the years.
• YOU ARE BECOMING COMPLACENT: You are very motivated as a surgery patient at the beginning, then become complacent and lose motivation over time, after losing a large amount of weight.
• YOU'RE OFF TRACK: You experience daily life stress that distracts you from your post surgery lifestyle priorities and better health.
• YOU ARE AFRAID TO BE JUDGED: You have gained weight back now that you are 3 or more years post surgery but are embarrassed to reconnect with your surgeon and supports in your bariatric community, patients and professionals alike.

In addition to team professional support from your bariatric surgery program here are a few things to consider:

• CONVICTION: Support and encouragement from family, friends and mentors. Those who have a vested interest in you and your success are the key people who help you post surgery and beyond. Try not to hear all or nothing of what others may say; seek what is helpful to you and leave the rest. Time and education help reassure those around you that your decision to have surgery is a sound one.
• CONSISTENCY: Staying on a regular schedule with the surgeon's office consists of regular lap band fills every 6 weeks or more, follow up visits with the nutritionist, regular blood work and support group attendance are ways to promote best results with your adjustable gastric band.
• SHARING AND RECEIVING: Many patients find the use of individual therapy helpful or a group setting to reinforce continuous learning and lifestyle improvements. This would be recommended in addition to program support group attendance.
• ONLINE SUPPORT SYSTEMS: Online resources are very helpful as an addition to program as well as personal support.

So here are the essential issues of bariatric living:

• Your consistent awareness of these issues will increase the effectiveness of your weight loss "tool" so you can maintain a long and happy partnership with it.
• It is an emotional adjustment at times and requires perseverance.
• You will bicker, even fight at times (with your band) and say things you will regret.

Just remember, the band can be very flexible at times and allow you make mistakes but it cannot help you if you do not help yourself. That's what life partners are supposed to do, right? They provide consistent support through all the ups and downs of life, through good times and bad.

You will have a long and prosperous relationship with your gastric band if you work as a team; isn't that really the goal, after all?

Related: Is the Lap-Band for You?

Risks with the Lap-Band

First, let's take a look at some of the possible risks or complications that can happen with the band. Nearly all patients get some sort of complications or side effects, but not necessarily severe ones. Excessive bleeding and blood clots are risks that you take with any surgery. Of course you'll have abdominal pain as you recover from lap-band surgery; after all, your surgeon had to make cuts in your stomach to put the lap-band in place.

These are some of the other risks with the lap-band:

• band slippage
• leakage
• band erosion
• esophageal dilation
• nausea
• vomiting
• trouble swallowing (dysphagia)
• obstruction
• constipation

Many of the complications are more common in patients whose starting weight (or BMI) is higher. That's obviously a potential drawback for higher-BMI patients, but it's also important to look at the alternatives. If your BMI is higher, you're at higher risk for obesity-related health problems if you don't lose weight. Also, many of the complications are preventable if you carefully follow your surgeon's post-operation instructions, especially regarding your diet.

Weight Loss to Expect

We know; here's what you're really interested in! How much weight will the lap-band help you lose? The numbers vary, but within a year of getting the lap-band and following the lap-band diet, you might expect to lose a significant amount of your excess weight. Your excess weight is the number of pounds over your goal weight, and you might be able to lose 40 percent - or more - in a year. Many patients have been able to maintain their weight loss for five or more years. That's great news if you're sick of watching your weight cycle as you try diet after diet!

The amount of weight you lose and whether you keep it off depends on you. To control your weight, you need to stick to your lap-band diet. These are the basic requirements of the lap-band diet:

• Choose nutritious foods
• Avoid high-calorie, low-nutrient foods
• Avoid beverages with calories
• Eat small portions
• Limit snacking

Exercise helps burn calories and speeds up weight loss, too!

Are You a Candidate for the Lap-Band?

Not everyone is eligible to get the lap-band. You have to meet certain criteria before you can get the lap-band. These are some of the normal requirements. Some of them are set by the FDA; others might be required by your insurance company or surgeon:

• Being at least 30 pounds overweight, with a BMI of at least 40 or a BMI of 30 to 40 along with an obesity-related health condition.
• Having struggled with your weight for at least five years, and having a history of unsuccessful dieting attempts.
• Being willing to attend educational seminars about the lap-band to learn about the procedure.
• Following a special diet program before your surgery to show that you're able to do it.
• Promising to follow your surgeon's aftercare program, which may include follow-up appointments, dietitian visits and group support meetings with other lap-band patients.

A contraindication is a condition that makes you ineligible or a poor candidate for getting the lap-band. These are some of the common contraindications:

• Heart or lung problems that can make your surgery dangerous
• Drug or alcohol addiction
• Low pain tolerance (you will feel pain after getting banded)
• Unwillingness to commit to the lifestyle changes and lap-band diet necessary for losing weight and preventing complications
• Pregnancy or planning to become pregnant within a year

Since the lap-band has such a long history, there's been a lot of research done on the risks and benefits of the procedure. Chapter 4, "Is the Lap-Band the Right Choice for You?," in The BIG Book on the LAP-BAND, goes through this research in more detail than this short summary. You'll get to see some of the particular numbers, such as average pounds lost or percentages of patients who have specific complications. This information, together with seeing the eligibility criteria, can help you make an informed decision about whether the lap-band is right for you.

Related: The Top 10 List of Things You Need to Know about Gastric Band Surgery

TIME FOR SOME TOUGH LOVE?

Genuine Jean Tuff Luv™? What's that? It's my version of the kind of love that hurts so good, because it gets you going in the direction you want to go.

Stern but caring parents, teachers and coaches who maintain strict rules and demanding training regimens are said to practice tough love. Those rules and regimens may not be fun, but they can turn around kids, students or athletes who've gotten off track or are underachieving.

Tough love may seem too severe, too tough. It works best when the parent, teacher or coach believes in, proclaims, and respects the inherent value and purpose of the person they're trying to help. Sometimes all we need is a wakeup call to shake us out of our stupor and pull us out of a rut. The drills and discipline of tough love can help (even as they hurt) when our bandwagons have gotten lost or stalled somewhere along the way to success.

A bandster once said of me, "Jean tells people the things they don't want to hear." I chose to take that as a compliment. Many times in my life, I've benefited from a slap upside the head by a concerned friend. When I do the slapping, I try to do it with just enough emphasis to get a friend's attention long enough to deliver an important message, followed by a gentle and loving kick in the butt. So here's my top 10 list of things you need to know about adjustable gastric band surgery. Consider yourself kicked!

THE GJTL TOP TEN LIST

1. You will not wake up in the recovery room at your goal weight. Average weight loss with the band is 1-2 pounds per week, and virtually no one loses weight at a nice steady pace of (say) 1.75 pounds per week. Some weeks you'll lose, some weeks you'll stall and some weeks you'll gain, but as long as the overall trend is downward, you're doing great!

2. Slower weight loss with the band does not prevent sagging or excess skin. How your skin reacts to massive weight loss depends mostly on your genetics and your age. As we age, our skin loses elasticity. If the possibility of sagging or excess skin worries you, start tossing your change into a plastic surgery piggy bank.

3. Weight loss surgery (of any type) does NOT cure obesity. Obesity is a chronic and incurable disease characterized by relapse and recurrence. Although bariatric surgery is currently the most effective way of treating obesity, obesity is something you're going to have to manage for the rest of your life, with or without surgery. For most of us, a tool like the adjustable gastric band makes that a lot easier, but it's not effortless, either.

4. Most eating problems after band surgery are due to user error, and can be prevented by using good band eating skills. Read an article about those skills by clicking here: How to Eat Like a Bandster.

5. to decrease your weight and increase your health, you must decrease your food intake and increase the quality of your food choices and the time you spend exercising. While you may be able to lose weight for a while by just eating much smaller portions of Chicken McNuggets, potato chips, and candy bars, eventually that approach will stop working, and at the same time it will start biting your health in the butt. And though it may be difficult for you to exercise at first, each pound you lose will make it easier, and each additional hour you spend exercising will not only burn calories but improve your physical and mental health.

6. No weight loss surgery procedure will cure eating disorders, eating demons, emotional eating, boredom eating, stress eating, celebratory eating or food addiction. Changing those behaviors is your job. If it's too hard to tackle yourself, consider getting some counseling with a therapist experienced with eating disorder and WLS patients, and/or joining a 12-step group like Overeater's Anonymous.

7. The band rarely works without fills. Even if you initially lose weight with one or no fills, sooner or later, you're going to have to face the fill needle. And if you're too needle-phobic to tolerate a fill needle, why did you choose band surgery in the first place?

8. The restriction "sweet spot" is a myth. There is no such thing as "perfect" restriction, or if there is, you can't count on it to last more than one hour, one day or one week. This is because the band is an inert silicone object implanted in a living, breathing human body that changes constantly in reaction to the time of day, time of month, time of year, hydration, illness, medication, stress, you name it. Restriction variability is part of the gastric band package.

9. There is nothing magic in the band that makes you lose weight. Changing your eating and exercise behavior is what makes you lose weight. All the band does is make that work easier for you by reducing your physical hunger and increasing your satiety.

10. YOU are responsible for your weight loss. Not your band, not your surgeon, and not the server at McDonald's who invariably asks you, "Want to supersize that?"

Related: DON'T Have Band Surgery If....

No, I haven't lost my mind. I still think the band is grand and I still wish I still had mine, but because I want everybody to succeed at weight loss, I feel duty-bound to tell you some reasons not to have adjustable gastric band surgery.

So here goes, in no particular order.

Don't have band surgery if…

You're phobic about needles. Right now, a needle is the only way to get fluid into the band. The fill needle is not a big, scary one, and you don't have to look at it at all if you prefer, but it's still a needle.

You believe that band surgery cures obesity. Obesity is an incurable, chronic disease with the very real potential for recurrence. Weight regain can happen to anyone.

You think that once you get to your goal weight, your weight loss journey stops. Nope. It's only just begun. Next you'll have to maintain that weight loss for the rest of your life, and that takes vigilance and hard work.

You're a self-pay planning on having surgery in Mexico or elsewhere out of country. What are you going to do if you have a problem or complication or just need another fill or unfill? Travel back to the Mexican clinic? Try to get help locally? Finding a US-based bariatric clinic that will accept patients who had surgery overseas is not easy, and once you do find one, you're probably going to have to pay a non-refundable program fee, from $200 to $2000.

You can't afford the time and expense for frequent follow up visits for fills, unfills, and other medical care. Even if your insurance covers those visits, you'll have to take time off work, arrange for child care or pet care, fill your car's gas tank, and shell out a co-pay.

You're a self-pay and don't have money or plans for dealing with fills, unfills, and possible complications. See above.

You hope to lose weight without getting any fills. Sorry, but it probably won't work that way. See above.

You expect to lose a pound+ a day. Average weight loss with the band is 1-2 pounds/week. That average includes people who lost weight faster as well as people who lost no weight at all. Rapid initial weight loss is usually related to fluid retention, not fat loss.

You believe that slow weight loss with the band will prevent sagging skin. According to several plastic surgeons I've asked about this, your age and genetics have the most influence on how your skin will respond to massive weight loss. The rate of weight loss has little or anything to do with it.

You expect to experience restriction and lose weight steadily from the moment you wake up after surgery. Most band patients need several fills to achieve optimal restriction, plus more fills and unfills (or adjustments) to maintain that restriction, and virtually no one loses weight at a steady rate. My weight loss was extremely uneven - down 1#, down .5#, up .75#, down 1.75#, down 0/up 0, down .25#, and so on.

You believe in the sweet spot or perfect restriction. Restriction is constantly changing, just like our bodies, because of dozens of quite ordinary factors (food choices, eating and drinking habits, weight loss, time of day or month, illness, medications, stress, etc.). If you think you'll lose weight only at the mythical sweet spot, you're going to spend energy on frustration that could be better applied to changing your eating behavior.

You're not willing to follow pre- and post-op liquid and puree diets. No, liquid and puree diets are not fun, but they're short-term. When I was banded, I had 36 years ahead of me, assuming that I live as long as my mother did. That's 12,672 days. My pre- and post-op liquid diets used up a whopping 17 days. Do the math. Even if you add in post-fill liquids and purees, those liquid and puree days represent a teeny, tiny fraction of my life.

You believe you'll never be hungry again. Maybe, maybe not. The fact that you feel hungry 5 hours after a meal doesn't mean your band isn't working. It just means that your body needs fuel. And part of your ongoing work as a bandster is going to be figuring out whether you're feeling physical hunger or "head" hunger.

You think the band is going to do all the work for you. The band has no magic ingredient that triggers weight loss once it's wrapped around your stomach. All it does is affect your hunger and appetite. The band is not going to make good food choices, practice portion control or banish the demons who make you eat when you're stressed or bored. Nor is it going to exercise for you. Success with the band is the result of a joint effort between you, your band, your surgeon and dietitian.

Have a don't-have-band-surgery reason to add to this list? Post it in the comment section!

Related: With This Band...

If you've been married as long as I have (we just celebrated our 25th wedding anniversary), you'll probably know what I mean when I say that at times, my relationship with my husband is a love-hate thing. The hate is provoked by stupid little things, like: why must an adult male in good health and in possession of all his faculties spit toothpaste on the bathroom mirror every single day of his life? Ten minutes after wanting to throttle him for that, I catch a glimpse of him cuddling a tiny kitten and my heart melts. He has truly been there for me through thick and thin (more thick than thin) and I can't imagine life without him, but the next time I walk into the bathroom and see the Colgate version of a Jackson Pollock painting on the mirror, my husband's life will hang by a thread, at least for a few moments.

I also have a love-hate relationship with my band at times. I resent it because it prevents me from eating mindlessly. I love it for the very same reason, but when I'm tired or hurried or distracted, the effort to eat carefully seems enormous. Why can't my band just do its job and leave me the heck alone? I'm by no means a lazy person but there are days when living with an adjustable gastric band is a lot of work. It's certainly not a spectator sport - to win this game, you have to jump right in and get busy, and it's not over when the cheers fade away…it starts all over again the next day, and the next day, for the rest of your life. Like me and the stupid bathroom mirror.

Happily Ever After?

I think that many people have bariatric surgery believing or hoping that it will solve everything, that they'll never have to struggle with their food or eating again. Most of the time, that's not the happy ending to their story. Their story has a different ending that could be happier if they adjust their thinking to it. Is the burden of good eating choices too heavy? If surgery helps you lose all the excess weight, shouldn't it help you maintain that weight loss without another thought for the rest of your life? Dream on.

I've seen a lot of bandsters (including the short blonde one in that bathroom mirror) crash into the Forever Wall, kind of like hitting the "seven-year itch" in a marriage. We prepare for band surgery with all the hope and care of a bride and groom planning a wedding - what we'll wear, what we'll eat, what music we'll dance to. We enjoy a romantic honeymoon with the band, things go great for a while, and then things get harder and harder. At that point, you can fall in love with another bariatric procedure, believing that a revision to gastric bypass or whatever will hand you the key to happily-ever-after. Or you can stick with the partner you've already got, survive some tough times, and come out of it all the stronger.

My friend Tami send me these wise comments:

"Your comparison of WLS to marriage made me chuckle. One time my daughter asked me whether I'd ever divorce her dad (sometimes he can be such an ass!). I said, "Absolutely not. He's family. You sometimes can't stand your brother, but you can't divorce him." Now, if there was a serious "complication" in my marriage, like abuse, I'd have to reconsider my options. And that's exactly how I feel about my band. It's part of me, and as long as it doesn't abuse me with serious complications, we'll stick together. And just like my husband, I have to respect my band, take care of it, and learn from mistakes."

To Have & To Hold - til it's no fun any more?

I've survived some complications with my band that I suppose you could classify as on the low side of serious: a band slip, and a flipped port. Since the actions my surgeon and I took in response to these complications were swift (in the case of the slip) and sensible (in the case of the port flip), neither one of them ever endangered me - not in terms of my health, and not in terms of my quality of life. In fact, they seemed quite minor to me compared to other problems that my fellow humans face every day - a terminal cancer diagnosis; a fatal automobile accident; a crippling disease; the loss of a partner; parent or child - that except for the occasional moment of frustration or angry, "Why me, God?", I just kept trudging onward. Perhaps another person with a different world-view and/or different expectations would consider a band slip grounds for divorce. I can't criticize people who choose divorce, whether it involves their spouse or their band. Only I can decide what's acceptable and tolerable for me, and others must decide that for themselves. But if you walk down the church aisle three minutes before your wedding begins thinking, "If I don't like marriage, I can always get a divorce," perhaps you don't belong in the church in that fancy get-up in front of all your family and friends after all.

At this (fairly advanced) stage of my life, I'm convinced that God or the universe throws nails on the road before me as a way to get my attention, make me stop and get my bearings, make me enjoy the scenery and make me appreciate how far I've traveled so far. So I do my best to learn what I can from each challenging situation with the gastric band that's complaining or my husband who's vigorously brushing his teeth or the dog who's chewing on a chair leg. For all I know, my greatest goal in life is to be a champion cleaner of bathroom mirrors!

Related: Considering Lap Band Surgery? Know Thyself First

You're ready...

Ready to make a significant change in your lifestyle, your health and your well-being.

You're tired...

Tired of trying the latest, the "greatest", the easiest, the fastest...the next "big thing" in weight loss or the tried-and-true that seems to work for everyone BUT you.

You've made the decision to pursue Lap Band surgery and you're on your way. The journey may not be fast - psychological evaluations, requesting a recommendation from your primary care doctor, undergoing pre-op qualifying procedures and perhaps even trying one more time to follow another "diet" plan to satisfy your insurance companies' requirements.

There is a method to all of this madness - a point to all the hoops you need to jump through to have this life-saving surgery. You will be asked a LOT of questions - some of them very personal and some of them more difficult than others. While you are undergoing the pre-surgery qualification process, whether it is short or long, I want to encourage you to do one more piece of analysis and introspection: a Personality Assessment.

What does your personality have to do with your potential success as a Lap Band surgery patient? A lot - in fact, some might say that knowing your personality type and how it will affect your interactions with medical and support staff can be one of the critical determining factors for your level of success beyond the surgery.

When I began my journey to qualification for Lap Band surgery in August of 2008, I was fortunate that the process for my employer was not an extremely long one. I needed a referral from my primary care doctor, which was fairly easy to obtain. I needed to prove that I had tried other weight loss methods, which was not difficult, since my most recent experiences in that area included one of the most popular group programs in the country, plus some lesser-known programs that had worked for a short while for me, but did not produce lasting results.

I also had to undergo a psychiatric evaluation to help the practitioner decide if my motivations for the surgery were reasonable and the results I was targeting were achievable. Superficial motivations like a new wardrobe or wanting to date more would not have cut it - and those were not part of my motivation. My main goals were to:

1) Get off of all medication - most notably the high blood pressure and diabetes medications, plus the potential for having another medication added for my recently diagnosed atrial fibrillation.

2) Stop and reverse the pattern of poor health that was present in my family. I had a deep and wide history of health issues in my family, from my mother and father to my older brother and sister, and 3 of my 4 aunts - all suffered with diabetes, high blood pressure and heart disease. I was determined not to add my name to the ranks of those whose cause of death could be traced directly back to those illnesses.

3) Live my healthiest possible life and extend my life expectancy instead of shortening it.

Once I began the qualifying process, I took what I knew of my personality type (I'm a Powerful Choleric) and used that to my advantage. That particular personality type is known for it's positive qualities (dynamic leaders, driven, determined) as well for it's negative qualities (stubborn, opinionated, controlling). Knowing this about myself helped me to prepare for my interactions with medical and support staff, and helped me to "turn down" my normal opinionated personality more toward one that was accepting, cooperative, and open to learning. I did not have to have all the answers anymore, just be able to find and listen to the people who had them.

My personality type served me well during the post-operative recovery period. My natural impatience, tempered with the information I had received and adopted from my surgeon, helped me to have a trouble-free recovery. Being willing to listen, comprehend and apply the knowledge I had made my transition easier. The drive and determination that is part of the Powerful Choleric's personality also drove me to start and stick with an exercise program during my recovery. I, who had never considered that I would run more than a few steps (or to chase down a young child), found myself running a 5k race.

The intentional action of discovering your personality type can also help you in advocating for yourself with medical and support staff. If you are a more laid-back personality - a Peaceful Phlegmatic, for instance - you might be inclined to simply accept what you are told and follow all recommendations to the last detail. That means it's important for you to know that your particular group of medical and support professionals is well-educated and abreast of the latest information so that you can be confident in their instructions and recommendations.

If your personality is more outgoing - a Popular Sanguine, for instance - it will be more important for you to affiliate with a medical and support team that has plenty of opportunity for you to interact with fellow patients, service providers, and others that can help make your Lap Band journey more in harmony with that personality's need for conversation and interaction. This personality type may also require more intensive follow-up and more frequent check-ins with medical and support staff. A more 'hands-off' type of program would not be optimal to ensure this individual's success.

The final personality type we'll discuss in this article is more reserved and introspective - the Perfect Melancholy - and they are more detail-oriented, serious and more inclined to be a perfectionist. This individual may have an easier time following recommendations or a "cookbook" of suggested actions for living a successful life after their procedure. This same quality, when taken to extremes, can cause an individual to become pessimistic and to drive themselves crazy with their efforts to measure up to their own high standards.

If some of these personality traits have made you curious as to which of the personality styles best fits you - realizing that most people are a combination of more than one of these at varying levels - then consider completing a personality assessment and using the information you learn from that to become a more educated patient. Knowing yourself more thoroughly can help you guide and adjust interactions with your medical team and support staff, and help you get the information you need to help you have a successful experience.

Related: 13 Things To Know About Living With the Lap-Band

1. Lap-Band and Other WLS Procedures. The Lap-Band can work as well as any bariatric operation, if it's done right, and managed properly. It is by no means a lesser operation. It does, however, need you and your surgeon to work, and keep working.

2. Follow-up With Your Surgeon. It's a two-way street. You have had your Lap-Band placed, which is usually a gentle, safe surgery that takes about 30 minutes, as a same day procedure. After surgery, you have to come regularly to have it adjusted, and your surgeon has to listen to you. I encourage my patients to come in for an appointment once a month for about 18 months, and in that time, they will normally get seven to eight adjustments. After that, it's usually four times a year for a couple of years, then annually, or whenever the patient needs an adjustment. We have an open door policy for adjustments. Your doctor has to listen to you.

3. Lap-Band and Hunger. The aim of the adjustment is to control hunger. If you tell me you're more hungry, if you're eating after dinner at night while you watch TV, if you wake up starving in the morning, then your Lap-Band is loose. You don't need to see a dietician, you don't need to go to the gym, and you don't need to change your diet. You need your band tightened a little.

4. What the Lap-Band Does. Having a Lap-Band is not about restricting yourself or not eating. It's about eating a lot less, feeling satisfied, and not being hungry after you eat. The aim of a Lap-Band adjustment is to reduce hunger, to reduce the urge to eat, and secondarily, to allow you to get full and satisfied quicker. When your Band is doing this, it's quite tight.

5. First Law of the Lap-Band. Which brings us to the first law of living with a Lap-Band. Like Newton's first law, it's absolute, and it's true...you can't live with a tight, well-adjusted band as if you don't have one. It will beat you every time. Every. Single. Time.

6. How to Eat With a Lap-Band. With a Lap-Band, you have to eat slower than you ever thought. It takes about 20 seconds for the esophagus to push a piece of food into the stomach. You have to eat at that rate, or food will get stuck, it will hurt, and you will have an uncontrollable reflex to vomit, to get that stuck piece of food out. I am lucky enough to be married to a great woman, Chris Ren, the Chief of Bariatric Surgery at NYU Langone Medical Center. She's a size 6 on a bad day. She doesn't eat much. Lucky her. With my Lap-Band, I eat about the same, or a little less than Chris. If I eat quicker than her, food gets stuck. For certain. Every time. So, mostly I don't. If I'm excited, say watching the Giants beat the Cowboys, and I forget and gulp a couple of bites of my dinner, she rolls her eyes at me. I shrug, say It's Eli, baby, and go to the bathroom. It's how it is, and how it always will be.

7. Eat Slower. I just don't understand the whole I can't eat this or that, especially about vegetables and salad. It is always, always, about eating slowly. If you work out the slow eating thing, and you keep your band adjusted, you will not regain weight.

8. Be in the Moment When Eating. The next law of living with the Lap-Band is to be in the moment. If you're in a nice restaurant with friends, or on a date, have a cocktail and relax. Order food you know you can eat easily - Oysters, soup, risotto, steak or tuna tartare, flaky fish, salmon, veal, stews. Order Sashimi, not rolls. Try tomatoes, lentils, beets or arugula. Have thin pasta, not rigatoni or lasagna. Have the pasta a little overcooked, not al dente. Get an 8 oz filet rare, and eat half of it. Don't eat the bread!! Push food around the plate. Focus on eating slowly. Stop when you've had enough. Don't mind leaving food on the plate (or take the rest home for another meal). Tell your dinner companions, if they ask, that you're watching what you're eating. Don't rush. Have a glass of wine. It will relax you, and your esophagus. Have two if everyone else is. Above all else, enjoy yourself. Make it not about the food, but the experience.

9. The Lap-Band is About Moderation. Don't obsess about what you choose to eat. Everything in moderation, like our grandmas told us. Skinny girls eat what they want. They just don't eat a lot of it. I eat less than my wife, but I eat what I feel like eating. Have a scoop of ice cream every now and then. Have a slice of pizza. When did a slice ever hurt anyone? It's when you eat a pint of ice cream or a whole pizza pie that it's a problem. Let the Lap-Band help you. All it asks of you is that you eat slowly. If it's adjusted correctly, you'll only want a slice, not a pie.

10. How to Take a Break. There's no harm in having a break for a week or two. If you're going on a trip to Paris, or Tuscany, and you've been waiting your whole life to try all the restaurants you've read about, and are nervous, loosen it before you go. Relax, enjoy the moment, then come back and get retightened. But make sure you get retightened, or you will regain weight.

11. Keep Your Adjustment. Everyone who empties their Lap-Band so they can eat "healthier" regains weight. A lot of weight. As sure as the sun rises in the morning. You can eat as healthy as you want if you eat slowly.

12. Eat According to Your Band and Time of Day. The power of the Lap-Band varies by time of day. It's because the esophagus's ability to push food is weaker in the morning. Have a cup of coffee, a little yogurt, a soft boiled egg, slowly. It's looser at night because the esophagus is pumping strongly. Adjust your Lap-Band to deal with the evenings, so you're not hungry after dinner, then adapt to having less in the morning. Emotions affect your Band. It's the stress hormones affecting your esophagus. If you're overtired, angry, sad about something or just plain frazzled, stop for a bit before you eat. Sit down, calm down, then eat your meal slowly. Put your knife and fork down between bites. Put the sandwich down between bites. Go slow. Wait until you've calmed down.

13. Stay Connected to Your Surgeon. The final thing I've learned is to stay in touch with your doctor. If you start getting hungry again, get a fill. Don't be embarrassed that you haven't been for a year or two. If you're getting hungry, if you're gaining weight, go back.

The Lap-Band works. You can't live with a Lap-Band WLS as if you don't have it!