Dr. Schulman

Karey, The roll of skin on the upper abdomen will always be there when you sit.....even the skinniest of skinny will have this. More important is how it looks to you when you stand. I think you could benefit from a fleur-de-lis incision......it will give you better shape because it will narrow you at the waist, which you cannot do with just the horizontal TT incision. But, do you need it? Probably not, but it will improve your shape and tighten the upper part of your abdomen. The answer is really about what you are willing to accept in terms of scars. The up and down scar will run from the bottom of the breast bone to the lower horizontal incision. It is a long scar and cannot be easily concealed. You really could go either way with this one! If I thought you would not benefit from the additional scar, I would tell you. It is a constant balance between shape and scar.....

It should be that low. Put a small stack of 4x4 gauze (maybe 4-5) under the drain so that the binder does not compress it against your skin. This should help.

the binder should be snug, but no too tight- you want to feel the support of it, but not have it cut off circulation. You probably will need to readjust it constantly throughout the day because it may "ride up" or slip down. One other thing, the "bright/dark red" drain output makes me raise an eyebrow. It is normal to have Fluid that looks red like fruit punch - light red, watery, thin. It is also common for it to be slightly yellow. Bright/dark red is a bit unusual for 10 days post op. Everyone is different, and this probably is not a problem, but you should at least run this by your surgeon.

I am glad you have lost more weight - it will only make your results even better after the TT. Cellulite can be improved with liposuction, but it needs to be done very carefully. Cellulite is not fat, it is fibrous bands that connect the skin to the deep tissue. The bumpiness is because these bands make little "fat compartments." Small and carefull liposuction can make this better because it breaks up the bands. If aggressive liposuction is done, it will get worse. I agree that the ads in those magazines are very misleading and I some might argue that the pics are digitally altered. The mons can be corrected with a monsplasty or lift, combined with lipopsuction. It works very well. I routinely fix this area when I do my TT or LBLs. See you at the walk.

It takes scars about 12 months to "mature." This means that the scar will continue to change for this time. Usually, it changes for the better. I recommend using a combination of compression and silicone. Compression over scars definitely helps - this is why I tell my patients to keep surgical tape (the paper tape) over the scars for 2 months. Also, there are several topical products available. Don't waste your money on Mederma. Get a product that is silicone based. I use something called Kelocote - it is a silicone gel and steroid. It works pretty well. You should be able to find it online and it is relatively inexpensive.

Linda, Sorry for not answering this....i am usually pretty good at answering promptly, but this one snuck by! I am not familiar with any PS in Boston. I would suggest checking at some of the large medical centers where you shouls find an experienced PS.

A boxy shape can happen sometimes after a TT. Plastic surgeons have many "tricks" to minimize this - including liposuction of the waistline during a TT. Sometimes it is unavoidable in certain body types. A midline vertical incision (fluer-de-lis) with a TT can be a very powerful way to narrow the waist and get a much better shape. This adds a major scar, but can improve the shape so much that many don't mind. Here is a picture of fleur-de-lis With this said, it has only been about 6 weeks since your surgery - this is very short, and you have a lot of healing to do. You are still very swollen, and it takes months and months (6-9) for the swelling to resolve. This means that your shape will get better and better over time. If this does not improve, the TT can be revised (with or without the midline incision) - but this is usually unnecessary. Regarding the wound healing problems, this may indicate that you are a "poor healer". The most common reasons are smoking and poor nutrition (low Protein, low iron). This is why proper nutrition, and ongoing relationship with experienced nutritionist is so important. More likely, the problems were the result of this particular surgery - since you have had smaller surgeries in the past without problems, probably means that you heal fine - "poor healers" usually have delayed healing from even very small procedures.

The incision that you refer to is called an "anchor" or "inverted T" incision. This consists of a vertical (up-and-down) line and a horizontal (the one in the breast crease). Some people complain about the horizontal incision - it is usually this part that has minor healing problems, can be irritated by bras, and are most prone to thick/raised scars. I always tell my patients to avoid underwire bras (besides...you won't need them anymore) New techniques allow for a breast reduction with only the vertical component - it is often called a "lollipop" incision, just like the one used for breast lifts. This eliminates over 60% of the scar, and avoids the problems associated with the horizontal part of the incision. I should mention that while more and more reductions are being done with this "lollipop" incision, it is not always possible after massive weight loss. This is because it may not allow for the best breast shape if there is a lot of excess skin - I have always said that weight loss patients have unique bodies that need very specific techniques.

Thanks to all who replied....I got many many great responses. I will start the process of going through all of them. I will try to incorporate everyone's feelings about the subject.

Occassionally, breast cancer is found in the breast reduction specimen. This is rare, and it is still unclear if it even matters if there are some small cancerous cells in it - some people argue that we all have some small amount of cancers cells inside of us and our body is constantly fighting it off... Regardless, it depends on the size, type, and location of the cancer that is found. Sometimes, the breast reduction is all that needs to be done - think of it like a large "lumpectomy." Having a breast reduction and the cancer "opened to the air" does not make it more aggressive. It may change the options a bit, because the surgery disrupts the normal lymphatics and will make lymph node mapping more difficult. Like I said, cancer is very rarely found on the breast reduction specimen if it was not seen on a pre-op mammogram. In this rare case, usually it is small (because it didn't show up on mammo) and contained completely within the specimen...meaning it is all out, and nothing more needs to be done.

The two procedures can be done at the same time. Depending on the specific amount of breast reconstruction that you require, it is possible to use the tummy skin and fat to reconstruct the breast. This procedure is referred to as a TRAM flap and has been used in breast reconstuction for about 15 years. The fact that you now have loose abdominal skin after your reconstruction makes you a great candidate for this procedure.

There seem to be a lot of you from Texas on this site.... a Texas office may not be such a bad idea Where are all my New York people at?

I responded to your pm, but for everyone elses benefit, I will comment again briefly. Any surgery can worsen liver problems - this is mostly because of anesthesia and the stress of surgery. Also, liver problems increase the risk of bleeding and infection. I am not aware of any specific risk of the lap band to the liver, but just the fact that it requires abdominal surgery and general anesthesia is a risk. You need to speak to your GI doc and Bariatric surgeon to see how significant the risks are to you -depending on your specific liver tests and other history. I can't comment more specifically without knowing more information, and liver is also not my area of expertise.

The skin will be a bitmore resilient - because the "new" abdominal skin is better quality skin that was at the upper part of the abdomen. But, weight loss after a TT (which is very common) may make the skin hang a bit - this is usually not anywhere as bad as before the original TT, but you will have to decide if it is bad enough to warrant another surgery -usually it is not a repeat TT, but a much smaller operation that just removes the skin (like a mini panniculectomy) so the recovery is much easier.

you have to chck with BCBS of Michigan to find out specifically what they require. Keep in mind, they will only cover a panniculectomy - a TT is always cosmetic. This may mean that if they cover the panniculectomy, you will be responsible for TT portion (check with you PS about what the cost difference is). For documentation, check with BCBS, but expect them to require that the pannus hangs to the pubis, documented infections, documented back pain or letter from chiropractor that pannus is worsening a pre-existing condition. You should schedule a consultation with a PS and they will help with the insurance submission - this may take several months, which is why you should start early.

It seems like you are doing all the right things. I always caution people to not focus too much on the numbers. 7 pounds of skin is actually a lot of skin - skin does not weight that much, so that is really significant, especially considering it is not your first surgery. Regarding the weight loss, you body will tell you.....if you are not losing weight despite the things that you are doing, your weight loss is probably done. Also, keep in mind that muscle weighs a lot more than fat - so as you exercise and add muscle, your weight will actually go up. If your weight is staying the same, then obviously you are also losing fat. You should be proud of this, not discouraged. This is why I say not to focus on the number too much.

My recommendation is to see a plastic surgeon when you are within 30 lbs of goal, or if your weight loss has stopped (regardless of where you are in relation to your goal). Keep in mind that about 10+ pounds will be skin, so you may not get to your goal weight. It may take a while to get an appointment and it may take several months to be scheduled, paperwork, etc., so best to start early. I don't think that a PS experienced in this area will be affected by your weight. We understand that everyone is different, and some people can not get to a low goal wight (or don't want to). We also know that lapband patients tend to lose less weight than other bariatric surgery (like GB or DS).

There is still time. I welcome any input you have. Thanks.

Congratulations on your weight loss. I think the best plan is to do the TT (or circumferential body lift) when you are close to goal - or at least when your weight loss stabilizes. It is true that you can loose more weight after the surgery. Also, with your 200+ pounds lost, I am sure you will have about 20+ pounds of skin...so you may never actually get to your goal because you should factor in the weight of the skin. The scar froman armlift will fade, but it may never disappear completely. The scar quality really depends on your body andhw you heal. When done correctly, it should not be visible from the front, back, or side with your arms down at your sides. If you develop large hanging skin, I am guessing that you will accept some scarring.

Fraxel works for fine lines, wrinkles, acnes scars, and pigmentation. It takes several treatments sessions (3-5, with a month between each). Chemical peels, and microdermabrasion can work well also. There is also surgical excision of the skin (blepharoplasty). With weight loss, the face loses fat as well. So much of the time, the treatment is to add volume - this will "inflate" the face and smooth out the lines and crepey skin. Here is an analogy - If you add water to a raisen, you get a grape. This is why PS talk about putting volume (fillers, fat, implant) into the face - when you just spent so much time, effort, and money to lose the weight.

I am glad I helped. A good rule of thumb is "the more you are willing to accept in terms of scarring, the better result you will get in terms of shape!"

Insurance will not pay for skin removal because there is no expense associated with it. The cost associated with the skin removal (packaging, shipping, paperwork, blood work, etc.) is entirely paid for by the organ foundation processing the skin. If this interests you, ask your plastic surgeon about it - some plastic surgeons like myself are doing it. Contrary to popular belief, skin from weight loss patients IS SUITABLE for donation (it is not too stretched out!). It was not possible a few years ago, but new technologies make it possible now. It is not made into the type of skin used for burn victims...rather, it is used as internal tisse during reconstructive surgery (large hernias, breast reconstruction, etc.) It is used in place of synthetic mesh. Donating does not effect your operation at all, and does not add any operating time. The only "inconvenience" is a 20 minute phone interview and some blood draw (when you are asleep in the OR).

I thnk this was also brought up on the "Ask Dr. Schulman" thread. While it is best to have a TT after you have all your children, there is no danger to you ro the baby if ou get pregnant after a TT. Pregnancy after a TT may reverse some of the results - the belly skin will stretch, the muscles will separate. These are all things taht happen normally during pregnancy - regardless of whether there has been a TT or not. The disadvantage is that your stomach may not be a "good" as it was after the TT and may require a revisional surgery. Many of my patients have gotten pregnant after a TT. Some of them are still happy with what their bellies look like afterwards, and some request small revisions. IT really depends on how your body reacts, but like I said, it is not dangerous to you or the baby.

I know of Dr. Katzen. He has a good reputation and the majority of his practice is related to weight loss surgery. He has a strong following of patients. He tends to be a bit on the aggressive side - long surgeries, and massive liposuction, etc. It is common for him to suction 10 L of fat from the legs before he does the LBL a few months later. I personally think that this leads to long OR times (8-9 hrs) and up to 1 week in the hospital, with increased complication risks. The data clearly shows that OR times exceeding 6 hours and liposuction exceeding 5 liters significantly increases the risks of surgery. While this very aggressive approach is not my particular style, Katzen gets good results and his patients tend to be happy, so I guess it works for him. I know the prices can be signficant as well given the extensive surgery, hourly rate for the OR, and overnight hospital stays. Regarding the time in the OR, every doc is different. Some work fast, and some have people helping them which enables them to cut down the OR time. Personally, I think 2-3 hours for an extended TT and breast lift with implants is way too short - I would be concerned that one person is working on the breasts while another is working on the abdomen. You should be sure of who the person is helping! I always do this surgery with a plastic surgery fellow (or two) and sometimes another board certified surgeon with me - I never have a technician or a nurse doing the surgery with me. I get paid for my skill and training, and it is not fair to the patient to have someone else perform a major portion of the operation. I consider myself fast, but it would take me about 2-3 hours for the TT and then another 2 hours for the breasts - for a total of 5-6 hours. Hope this helps.

I am working on an upcoming article about the psychology of obesity, for a popular magazine. If you are interested in being quoted, please private message me. Specifically, I am interested in: the psychological impact of being obese (personally, professionally, socially) the psychological impact of losing weight (the good, and the bad - has the weight loss improved things psychologically or has it actually made some things worse?) the psychological impact of having bariatric surgery (have people accused you of "taking a shortcut"?) I am looking to incorporate several "stories" into this article. Please send any information to me within the next week. I will contact anyone whose information will be used. If you want to send pictures too, please do. I appreciate the help - I know there will be some great stories from everyone here.