Dr. Schulman

Fat injections have been controversial. The problem is that about 40-50% of the fat does not survive transplantation. In areas such as the face, this can be a problem because it can lead to lumps. Also, there is significant swelling that can last for weeks. This is why I prefer other materials (synthetics like restylane, radiesse, juvaderm, or sculptra) for the face. In the buttocks, fat works very well. A lot of fat needs to be injected to compensate for about 50% "loss." After this procedure, you would need to stay off your buttocks for 2 weeks while the fat "takes." This means no sitting on your butt or laying on your back. This would be very difficult after a belt lipectomy or Lower body lift. One of the best around at this procedure is Constantino Mendietta in Florida. You can find many articles about fat transfer to the buttocks written by him. There seem to be 2 options. You can do the lipectomy and then have the fat injected several months later when you are more recovered and can be careful with the newly transplanted fat. The other option involves autologous buttock implants. I have developed my own technique where the tissue from the lower back is not discarded, but placed in the buttock as an "implant." The key is that the skin and fat is never disconnected from its blood supply, so it is alive, and near 100% survival. It does not need any special care afterwords - unlike fat transplants. I do this on about 75% of my lower body lifts because as many of you know, the butt tends to get even flatter after the surgery. I will post pictures of this autologous buttock augmentation tomorrow.

I thought that this might be a good place to post questions to me, so that other people can see your questions and my answers. I will continue to answer questions from those of you that private message me, but this is a nice way to share the information with others - since many of your questions are relevant to other people. I will try to answer the questions as quickly as possible, and include links and pictures when appropriate. I am obligated to add this disclosure.....any information provided by me is my opinion and cannot substitute for an actual consultation with your qualified physician.

Here is my way to help minimize brusing in my patients: I make sure that all my patients stay away from the following medicines for at least 10 days prior to any procedure - aspirin, motrin (ibuprofen), Vitamin E, and any aspirin or ibuprofen-containing medicines (like alka-seltzer cold and over the counter sinus or allergy medicines). Check the active ingredients because many common medicines contain aspirin or ibuprofen. Also, stay away from RED WINE - the reason it helps the heart is becasue it is a "blood thinner", which will make you more bruised. I also recommend taking arnica - this is an herbal supplement that may help decrease brusing and swelling. The data about this is 50-50, but many of my patients swear by it. The key is that you should start taking your arnica 3 days BEFORE a procedure and for at least FIVE days after. Immediately after a procedure like injectables, ICE ICE ICE. This should be doen as much as possible for 48 hours. This will reduce bruising and swelling. At about 1 week, when the bruises become the darkest, use WARM compresses to help break up the bruise. This will make it go away more quickly. For camoflauge of bruises, my office offers Lycogel makeup (I have no financial interest in this product) and my patients find that it is hevy enough to cover-up dark bruises. It is a silicone base, so it goes on smooth, and is available for all skin tones. You should be able to find this product in your area. Following these guidelines should help minimize brusing after injectables and get you back in public quicker. On a side note...... Here is an article that I wrote that you might find interesting - it is about a completely "non-surgical" facelift that was featured in the March issue of Healthy Aging.

When performing breast lift with implants in a weight loss patient, I almost always use an anchor incision. Yes, this is a more extensive incision, but most weight loss patients require more extensive "remodeling" of their breast tissue. In other patients (not weight loss) I am usually able to do the surgery with just an incision around the nipple-areola-comlex. There is an occassional weight loss patient that will do ok with the smaller incision, but in my experience, this often leaves them "undercorrected." Regarding the cost of breast implants.....doing a breast lift with implants can be a complicated procedure - especially in weight loss patients. It is not accurate to think of it as just doing a breast lift, then putting in implants. The cost will reflect this and there is great variability between surgeon and region (or country). I can tell you that a pair of silicone implants costs around $1800 and saline about $900.....this is just the cost to buy them, and does not reflect the procedure cost. I can only comment specifically about my fees. My fee for a breast lift is around $6,000-8,000, and my fee for breast augmentation is around $8,000-10,000. A breast lift with implants is usually around $10,000-12,000. Hopefully this information helps. The fees are a guideline and will vary between surgeons and regions - I am in NYC and the prices tend to be slightly higher than in other regions.

Salsa, Before surgeries I always require that my patients have a complete physical from their primary MD. this ensures taht everything is OK for surgery - and general anesthesia. Obviously, many of my procedures are "self-pay" and I have never heard of a PCP not submitting it to insurance. As a plastic surgeon, I also order lab tests on my own. I give the patients a prescription for bloodwork and they have bloodwork (and EKGs) performed at an outside facility that participates with their insurance (such as Quest Diagnostics, etc.) The fact that I (a Plastic Surgeon) am the ordering physician on the tests does not influence insurance coverage. Insurance ocverage is determined by the specific person (or facility) doing the procedure - ie. the lab. While I can't make recommendations to you, I agree with the previous posters that stated that these tests results are valid...regardless of whether it is for a cosmetic procedure. Speak to your PS and she should be able to order the tests, or at least give you the name of another PCP who will do the appropriate thing.

Nutrition testing is important for PS. This will give an indication of how well your body will heal after the procedure. Nutritional deficiencies are much more common after other types of bariatric surgery (gastric bypass, duodenal switch). Testing just requires basic lab tests which are very standard. I am suprised that you will have to pay out-of-pocket for this bloodwork. Generally, my patient's insurance covers bloodwork (even if it is for a cosmetic procedure). You may have to go to a laboratory that participates with your insurance, or have your primary doctor draw the labs for you. Another thing you should all be aware of...when the skin is removed, it must be sent to pathology. This is a law (and might vary between states). This allows the pathologists to examine the tissue and make sure there is nothing unusual...and is extremely important with breast surgery. You will likely get another bill from the pathologist and it may be around $100-$200 per specimen. This should also be covered by your insurance as long as the pathologist participates (even for cosmetic surgery). Again, some of these rules may vary state-to-state, and you should check with your insurance carrier.

I agree that it is never "too early" to begin the consulation process. Your plastic surgeon can help you determine the best order of body contouring procedures and some surgeries do not require that you are at you "goal weight." Also, a PS will be able to give you price quotes which will help you plan financially for your procedures. While mst PS offices can give you a price quote over the phone, the final fee will usually vary depending on your specific body type and needs. Therefore, only after your consultation, can you get an accurate fee estimate. Regarding ideal body wight and BMI, there are some things to keep in mind. I routinely remove anywhere from 10-30 pounds during the typical TT in people with bands. This means that may people will neer reach their goal weight before plastic surgery, becasue the excess skin has significant weight. It is more important that the weight loss stabilizes, and less important what teh actual number is.

I commonly perform combined procedures. An arm lift can be done at the same time as a TT. It will make the recovery more difficult because your arm activity will be limited which may make it more difficult to take care of your abdomen. Combined procedures can be done in motivated patients by experienced surgeons. It should help lower your out-of-pocket expenses because most surgeons will give a reduction in price when procedures are combined. You will also save money on the anesthesia cost because as a surgery gets longer, the hourly rate for the OR goes down. For example, the cost of one 6 hour surgery will be less than the cost of two 3 hour surgeries.

While Insurance will pay for a procedure if it is "medically necessary", it is almost impossible to demonstrate necessity in regards to arms. Those of you who have seen me speak at support groups may have heard this story before....It is the only example that I have heard of where insurance has deemed an armlift as "medically necessary." It is not a patient of mine, and I believe it was in the state of NY: A woman worked in a kitchen and sustained a burn to her upper arm because the excess skin touched a hot pot while cooking. She appealed to her insurance company claiming that it interfered with her work and was a danger to her. Only after 3 visits to an emergency department for treatments of these burns, did her insurance company agree that it was medically necessary. This should demonstrate how difficult it is to have arms covered by insurance. If anyone has any success stories, I would be interested in hearing them.

There is no problem in getting a second tummy tuck. The muscles can be "re-repaired" and any excess skin can be removed. The recovery from a second TT is usually a bit easier than the first time around. Keep in mind that while the skin may stretch and the muscles may "loosen" during pregnancy after TT, it may not be very extensive and it is not a given that you will need a "re-do TT."

This has been covered on here before, but it can never be repeated too often because it is so important. When choosing a plastic surgeon for body contouring, make sure he/she has the following qualifications: 1. Board Certified by the American Board of Plastic Surgery (do not be fooled by people who state that they are "board certified cosmetic surgeons" - this is not the same and requires nothing more than a membership fee) 2. Members of the American Society of Plastic Surgeons - this is the major plastic surgery society and requires that all its members are board certified, meet ethical and moral standards, and maintain continuing education through lectures and conferences. Check you doctor's status in the ASPS directory. 3. Your surgeon should be experienced with surgery on those who have had bariatric surgery. Body contouring after weight loss is a very subspecialized area of plastic surgeries. Just becasue your surgeons has performed many tummy tucks, odes not mean that they are experienced with performing tummy tucks on people who have lost 100 pounds - it is not the same. 4. Make sure your surgeon is performing your procedure in an accreditated facility. If it is beign performed outside a hospital (such as an ambulatory surgery center or his/her office, make sure they have admitting privledges at a nearby hospital, just in case of a complication. 5. Ask your surgeon how many procedures they have performed and ask to see pictures of the results. An experienced surgeon will be able to show you several examples, even of bad results! This is an important decision and you need to be safe. You deserve someone who is experienced and who will not compromise your safety. Obviously cost is always a factor, but don't use it as the only criteria.

Sue, I have never had a bariatric surgeon consult me regarding the location of the port becasue the port needs to be in a location that is best for fills - and this is often not the best cosmetic location. It is more important that you have a functioning port, thatis easily accessed, and will not "flip." When I perform a TT, I routinely have to move the port because of the amount of skin that I remove. Usually, the port is changed to a low profile port at this time as well. I can replace the port from the underside of the skin during the TT and this makes a completely scarless port site...the problem is that you will eventually have a scar if the port ever has to be changed or removed. In general, the scars from a plastic surgeon tend to be better (thinner, less red, flatter) than ones from other surgeons. We don't do anything magical - we just have special techniques and instruments that we use. So, when I replace a port during a TT, the scar tends to be much better than it was the first time. Occassionally I am called into the OR to close the port sites during the initial banding if the patient is extremely concerned about scarring.

It is my pleasure. I think it important that everyone gets a good understanding about plastic surgery - the good and the bad! It also works both ways. I learn a lot about what issues are most important to the patients, which helps me improve my practice by understanding these issues. Keep up the good work everybody!

As many of you know, I often speak at bariatric support groups in New York and New Jersey. One thing that never fails to amaze me, is how many people are surprised at the body changes after bariatric surgery. Many people had no idea that the skin may remain after weight loss and that needing (wanting) plastic surgery is extremely common. Patients are much more educated now about PS after weight loss - through support groups that sponsor plastic surgeons, through websites like this one, and in speaking with their bariatric surgeons. There is always room for improvement - especially on the "pre-op" side, so that you know that the weight loss may not always be the end of your journey. I am interested to hear your thoughts about the way in which you were educated about plastic surgery (or not educated), and whether this occurred before or after your band procedure. This will help me be able to better educate people about this subject.

Using an implant during a breast lift after weight loss helps in 2 ways: 1. It helps restore the volume that has been lost during weight loss. Most women's bresats are over 50% fat tissue, so as you lose weight, you will also lose volume in your breasts. 2.It helps adds fullness to the upper portion of the breasts. After weight loss, this upper part, or superior pole, becomes very flat. A breast lift (without implants) often does not add much volume to this upper pole of the breast. There are newer techniques that have been developed specifically for women who have undergone weight loss, desire more volume (particularly in the upper pole) but do not want an implant used. Experience bariatric plastic surgeons can perform this technique and give the appearance of implants...even though there were none used. Here are two examples of women who wanted the look of an implant...without the implant. The technique uses the extra skin from the side ("bra roll, "side roll") and transfers it to the breast to act as an "implant" of your own tissue. Example 1Example 2 I hope this information helps.

Pregnancy after a TT or body lift is not dangerous to you or the baby. It should not have an affect on pain level during pregnancy or delivery. The problem is that pregnancy will stretch the skin and disrupt the muscle repair. The skin should shrink back, but will not ever be as tight as it was before the pregnancy. I routinely ask my patients if they are planning any pregnancies. If they are, I recommend waiting because they will get a better cosmetic outcome. Some women do not want to wait until after pregnancy for a TT, and I have no problem performing it...as long as they understand the implications.

I think there is some truth to that. The only way to really help lift the outer thighs is through a lower body lift (this helps the abdomen, outer thighs, buttock and lower back simultaneously). The inner thighs would need a medial (inner) thigh lift. Doing these two operations at the same time may compromise the blood supply and may increase the possibiity of complications. A LBL is a large operation and I generally do not perform any other significant procedures at the same time - I will do liposuction of other areas at the same time. Many of these procedures can be combined.....but a LBL is the largest of all the procedures and should be done alone.

Hopefully I can answer your questions. 1. Regarding the inner thighs - This area is best addressed with an inner thigh lift in which the incision is maintained in the groin crease. Given your amoutn of successful weight loss, your surgeon may recommend an "up and down" incision as well for better contour. Yes, during a TT or LBL, your surgeon can remove some of this skin, without doing a "full" thigh lift, and this can give improvement - but it may not give you the improvement you want. 2. Regarding the skin overhanging the bra - This problem is common after weight loss and will not be improved significantly with an arm lift. This area is better addressed with an upper back lift, or upper body lift. In this operation, the skin of the underarms and upper back is removed, and the scar goes accross the upper back and is hidden under the bra line. This can be perfromed in combination with other procedures such as breast reduction or arm lift. Hopefully this helped. Obviously this information should not replace an actual consultation with your surgeon.

Mandy, You raise a good point about making sure your PS is board certified. I would add 2 more criteria for choosing your PS: 1. Member of the American Society of Plastic Surgeons (ASPS) - Board certification is only one criteria for being a member of ASPS. They also have to go through a selection process, meet a certain moral and ethical standard, and mainatin continuing education through conferences , lectures, etc. You can check to see if your surgeon is a member of ASPS at this link. 2. Specialize in body contouring after bariatric surgery - As you all know, your body goes through tremendous changes after lap band surgery. Many of these changes are unique to bandsters and very very different people who lose weight through diet and exrecise alone. Your PS should have experience with bariatric surgery and be experienced with massive weight loss patients. Safety should always be the first priority. Be selective in your choice and choose someone qualified to give your the results that you want - in a safe manner.

What you describe is unfortunately very common in overweight people who have had multiple abdominal surgeries. It sounds to me that you would be a candidate for abdominal wall reconstruction with a component separation. During this procedure, an incision is made, and the hernia is repaired by moving some the muscles from the flanks, towards the center to close the hernia. Depending on the size, this can be done on both sides. The incision can be either through the midline (where your scar is) or through a tummy tuck incision, which might get rid of that midline scar at the same time. Commonly, extra skin is removed during this procedure. The abdominal wall is routinely made "tight" during this operation. That being said......This is a large operation (but commonly performed by board certified plastic surgeons) and you might get a better aesthetic result (ie. tighter, flatter, thinner...) if you lose a large portion (if not all) of your weight before doing this. Because your hernia sounds large, there is actually LESS chance of any intestine getting incarcerated ("stuck") as compared to a small hernia with a narrow opening. This means that it is uncomfortable and unsightly...but not an urgent matter right now. If the bulge gets "stuck" and you can't push it back, or you have increased pain, or vomiting, then you should obviously see your doctor right away. I hope this information helps. Remember this is just my opinion based on the few details that you described and should never take the result of an actual consulation with your doctor.

As you know, silicone implants have been re-approved by teh FDA. Like most plastics surgeons, I had been using silicone implants all along for breast reconstruction and have had no problems. Any possible connection wiht cancer/lupus/arthrits/autoimmune disease has not been shown. Yes, silicone implants look and feel better (more natural and no rippling). There are some disadvantages though: 1. Silicone implants are prefilled and require a larger incision to place them. For most of you needing a lift as well, this is not a concern. 2. Becasue they are prefilled in 25cc increments, it may be difficult to choose the correct size if you have some significant breast asymmetry. (unlike saline which are filled at the time of surgery and can be adjusted to coorect for discrepencies) 3. Because ruptures are difficult to detect, the FDA recommends MRI exam 2 years after implantation and then every 3 years. This is time consuming, and not covered by insurance unless a rupture is suspected beforehand. In my practice, I am about 75% silicone and 25% saline for all cosmetic breast cases (including breast contouring after weight loss). Talk to your surgeon and he/she should be able to list all the pros and cons of each implant type.

I think you should be prepared to be out of work for 2 weeks. It maybe slightly less, but you have to see how you feel. There will be little discomfort after the first few days - actually, most people find beast reduction surgery quite tolerable. The thing to keep in mind is that your body uses a lot of energy to heal the wounds, so even if you don't have pain, you will feel tired for several weeks. Many of my patients with a desk job go back to work after 1 week, but it all depends on your situation and yor recovery. I would advise you to ask for 2 weeks, knowing that you may return sooner. For breast reduction pictures, click here - Breast Reduction | Madison Avenue Plastic Surgery

It is quite common to have a radh or irritation from the binder. This is partly because of moisture that can build up beneath it and the fact tthat the binder may not be the best qualitiy material. Cortisone cream may help, but tends to only offer symptomatic relief from the itching, not from the irritation. it may also promote fungal growth. The best thing to do is to wear a large T-shirt and then place the binder over that T-shirt. This should help. Another thing you can do is purchase another binder that may be better quality material - they are available at most medical supply stores, and many of my patients have been happy with Spanx. If the problem persists, call your docotr. I suspect he or she will tell you to stop using the binder especially if you have been wearing it for a few days or a week - it woul dbe unusual for the port to "flip" after a few days.

"Cottage cheese thighs" usually indicates the presence of cellulite. Cellulite is not lumps of fat, as most people commonly think. Rather, it is a result of bands of tissue that connect the skin to the deper layers, resulting in dimpling of the skin and fat. This is difficult to correct but can be improved with careful liposuction by a qualified plastic surgeon. The best correction may be a lift procedure - if the "cottage cheese" is improved as you pull you thighs upwards with your hands, than this is what you can expect after a thgh lift. Unfortunately, it is difficult to correct and there is no clinical evidence that any topical lotions or creams will reduce the appearance. Some work is being done with lasers, although they require weekly treatments, can be quite costly, and have nto demonstrated significant results. As you say, be careful with tanning because the temporary improvement you may see should not outweigh the risk of skin cancer.

While insurance coveragecontinues to get harder and harder, my experience is that breast reduction continues to be among the easiest to be covered. Most insurance companies rely on the amount of breast tissue removed to be the major determinant of coverage. Typically, if 500 grams of breast tissue is removed from each breast, most insurance companies will cover the procedure, without needing any other documentation (histor of back pain, neck pain, rashes, etc.) This amount is not hard to get, especially if you are DD or greater and will be reduced to a full C. Your doctor should be able to estimate the amount of beast tissue that he will be removing. There is good and bad in relation to this criteria- the good: no need to document things like back pain/rashes/neck pain, which we all know is difficult to quantify, and as shocking as this may sound, many people lie about it. the bad: The final determination will have to be made AFTER the surgery and the amount removed will have to be contained in the official operative report. Like I said, your doctor should be able to estimate the amount he will remove, so there should be no mystery about coverage. Check with your insurance carrier about the specific guidelines, and then check with your doctor about the amount he plans on removing. 500 grams is typical for most insurance companies, but may vary slightly. I hope this helps. Good luck to you.