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.

Dr. Schulman...I finally was approved by my insurance for my panniculectomy. It only took 6 months and 3 appeals but I finally won! I'm scheduled for surgery December 5th. I haven't met yet with my plastic surgeon, other than my initial visit with him in April, but I have questions that are making me crazy right now and hopefully you can give me a quick reply. What is the down time usually for this surgery? I've been told by his office that it should be a 2 hour surgery and if all goes well, it will be a day surgery. Are drain tubes always necessary? If so, how long do they stay in? On a scale from 1-10, how bad will the pain be? I'm pretty tough, hopefully. I had bunion surgery 3 years ago and 4 hours later, I walked out of the hospital on my own and even went to get my prescriptions filled. My surgeons nurse said if I could do that, this should be a piece of cake for me. I've read everything I can find on the internet about this surgery but I do have these questions and hopefully you can help me. Thanks again for all your support and encouragement with this. It just shows that fighting for what you want so desperately can pay off...it has for me.

I am really happy for you. All your persistence paid off. A panniculectomy is an easier recovery than a TT because there is no muscle repair. Obviously, everyone has a different pain threshold, but I suspect you will be surprised by how little pain you will feel. I tell people that they will feel lousy for a few days and then pretty good in 2 weeks. You should expect drains (probably 2) and they usually remain about a week. You should make sure that your PS gives you all your prescriptions in advance so that you do not have to get them after the surgery. Congratulations and good luck. I know you will do great!

Hi Dr. I have a few more questions relating to face/neck lift.

How long should the surgery take?

Are sutures, staples, glue or a combo of all used?

I would like to come see you but I prefer not to have surgery and followup that far away, as I would have to drive myself or take the train alone.

The surgery can take about 3-4 hours. I use a combination of sutures and staples. The staples are only placed in areas covered by hair. I understand not wanting to travel for the follow-up. Most of my out-of town patients stay overnight after surgery in a local hotel and then will be seen by me the day after surgery. They are then seen 5 or 6 days later to get the sutures out, and then again the next week. After that, no followup is needed for a few weeks.

Dr. S:

Goodmorning and thank you beyond words for advising me to "run far" if I come across a surgeon who tells me to suck it up and continue to lose weight.

I had an appointment with my regular M.D. on Monday and after reviewing my weight loss, 92 lbs., reviewing my MRI on my spine, noting I had been treated for skin infections in that region, and seeing the P.T. indicating the redistribution of my weight after loss added stress to the area on my back where it is problematic...he concurred with going for a panniculectomy.

Today is my appt. with a surgeon who has had experience in recontouring after major weight loss. To make it all the better they accept my insurance! This clinic is also a spa in another section of the facility.

I signed a release of records for the PS and my physician has drafted a letter of support. The other documentation has been faxed to the surgeon and I some how feel that today, I will walk away with a plan. Hopefully I will have a surgical date as well.

Thank you for your advice on here. You are helping us all in ways you will never truly know.

Addressing the issue of poor body self image, infections in private areas and skin that droops and sags can be very self defeating and intimidating. Having the privacy of this small group and support of so many makes the journey lighter.

I will post back my results.

Appt. is at 3:15 in Tampa.

All...think high thoughts, light candles and if you are so inclined say a prayer for Patty.

Thank you!

Wishing you the best Patty!

Dr. Schulman: How important is it to massage incisions? How long and how often should it be done? Have you ever heard of putting essential oils, like lavender and frankencise on the incisions to aid in healing? Thanks!

Hello All:

I had my Plastic Surgeon consultation today. It was not a positive experience.

Doctor S. could you provide me with a good link to read more on the partial panniculectomy?

.............

This surgeon's office indicated the doctor had extensive experience with gastric patients. In reality, he showed me one photo of a patient who had lost 300 pounds ( "what you still weigh" ).

I had drafted a concise letter indicating the problem areas and where and why I was in pain. I listed all my medications, I am on Morphine, for the pain. I discussed my problem areas and what I expected to achieve at this first goal.

It was as if he read nothing I had prepared or nothing my doctor had sent him. Rather, he asked me why I was on Morphine, and where was my pain and why was I in pain.

He then asked me why I chose a Lap Band. I explained I had researched it and felt that it wasn't cutting any organs and was my preferance. He then began (selling me on) discussing a collegue in Tampa who did gastric bypass, the benefits of bypass and the rapid weight loss. He promoted this other doctor and his clinic, the support group and suggested I go to this doctor. (still no advice or examination on anything surgical)

Oh, the panniculectomy?

When I indicated I was not interested in a bypass and was there for a consult for the panniculectomy he said my rashes and skin irritations weren't that serious, he, infact, had seen patients who were hospitalized for such skin problems and those were the types of patients that qualified for removing the pannus but they had much larger hanging ones then I did.

He further stated that my BMI was too high, he had a "rule" that he only performed surgeries on patients who were around 32 BMI. He further stated that if I had a partial panniculectomy now, I was looking at a three month recovery with narcotics, problems healing and packing deep into my stomach until my wound healed.

I am mindful of Dr. S's words "run away fast". I left there feeling I had been dealt a very confrontational hand.

Other than picking up the phone and dialing doctors, is there another method of finding a qualified surgeon?

Oh, and the Morphine I am on for my pain? He has had plenty of patients on narcotics for pain! He also had seen "800 pound patients at the University of Iowa that had to be intubated from respitory distress."

Dr. S, somewhere in there are some questions but I am so confused and discouraged that I cannot seem to find a local doctor with the level of experience or even close to it for WLS patients.

Any suggestions on key words to ask so I can filter out those who seemingly want only to consult and not actually examine?

Other than reducing my intake to 600 calories a day ( because I don't actually need to exercise to lose weight ) and sucking it up until I am a 32 BMI, do you have any direction to offer Dr. S?

Thank you in advance for your assistance.

Hello All:

I had my Plastic Surgeon consultation today. It was not a positive experience.

Doctor S. could you provide me with a good link to read more on the partial panniculectomy?

.............

This surgeon's office indicated the doctor had extensive experience with gastric patients. In reality, he showed me one photo of a patient who had lost 300 pounds ( "what you still weigh" ).

I had drafted a concise letter indicating the problem areas and where and why I was in pain. I listed all my medications, I am on Morphine, for the pain. I discussed my problem areas and what I expected to achieve at this first goal.

It was as if he read nothing I had prepared or nothing my doctor had sent him. Rather, he asked me why I was on Morphine, and where was my pain and why was I in pain.

He then asked me why I chose a Lap Band. I explained I had researched it and felt that it wasn't cutting any organs and was my preferance. He then began (selling me on) discussing a collegue in Tampa who did gastric bypass, the benefits of bypass and the rapid weight loss. He promoted this other doctor and his clinic, the support group and suggested I go to this doctor. (still no advice or examination on anything surgical)

Oh, the panniculectomy?

When I indicated I was not interested in a bypass and was there for a consult for the panniculectomy he said my rashes and skin irritations weren't that serious, he, infact, had seen patients who were hospitalized for such skin problems and those were the types of patients that qualified for removing the pannus but they had much larger hanging ones then I did.

He further stated that my BMI was too high, he had a "rule" that he only performed surgeries on patients who were around 32 BMI. He further stated that if I had a partial panniculectomy now, I was looking at a three month recovery with narcotics, problems healing and packing deep into my stomach until my wound healed.

I am mindful of Dr. S's words "run away fast". I left there feeling I had been dealt a very confrontational hand.

Other than picking up the phone and dialing doctors, is there another method of finding a qualified surgeon?

Oh, and the Morphine I am on for my pain? He has had plenty of patients on narcotics for pain! He also had seen "800 pound patients at the University of Iowa that had to be intubated from respitory distress."

Dr. S, somewhere in there are some questions but I am so confused and discouraged that I cannot seem to find a local doctor with the level of experience or even close to it for WLS patients.

Any suggestions on key words to ask so I can filter out those who seemingly want only to consult and not actually examine?

Other than reducing my intake to 600 calories a day ( because I don't actually need to exercise to lose weight ) and sucking it up until I am a 32 BMI, do you have any direction to offer Dr. S?

Thank you in advance for your assistance.

Patty,

I am sorry this have turned out to be such a bad experience. Many PS have "rules" about not operating on people with BMIs above arond 32. This is because the risk of complications dramatically increases. It is not uncommon to then suggest a revison bariatric surgery, such as conversion of a band to bypass. I have had this same conversation with several patients. The problem with this "rule" is that is fails to recognize the specific situation of each individual. This is where the "art" of plastic surgery comes in. The fact that you are having so much pain makes you an candidate for a panniculectomy. You have a higher risk for complications - usually not serious ones, but more like wound healing problems, fluid buildup, etc. I like to call these "nuisance" complications. Having the surgery will take a compromise on both you and your surgeon. You have to accept the increased risk of complications, and the surgeon has to be able to perform a panniculectomy in an efficient manner in order to limit anesthesia time and minimize risks. This may mean that you will have a slightly less than perfect cosmetic result - but that is ok because this is not a cosmetic procedure in your situation.

Don't be discouraged, and keep looking. Try looking on obesityhelp.com for surgeons (they have listings by states and patient reviews). Also, you can look on the american society of bariatric plastic surgeons (www.asbps.org) for a listing. When you think you have a few names, have your primary doc (or bariatric surgeon) call the doctor BEFORE you see them, and explain your situation and your necessity for a panniculectomy. You can then choose the PS who seems most "open" to operating on you.

Good luck, and continue to keep us posted.

Wishing you the best Patty!

Dr. Schulman: How important is it to massage incisions? How long and how often should it be done? Have you ever heard of putting essential oils, like lavender and frankencise on the incisions to aid in healing? Thanks!

it is really onlynecessary to massage scars if they get firm and raised. If they are healing normally (flat) there is nothing that you need to do. They will remain red for many many months. Regarding the oils, there is no scientific data that it helps. But, it won't hurt so you can if you want to. Most likely, it may help because it is moisturizing, not because of any specific essential oil. That beign said, I have many patients who swear by cocoa butter and who am I to say don't do it. I usually recommend a scar gel that has silicone in it. There are a few on the market and I am not sure if one is better than another. I usually use kelocote in my office, which has silicone and a steroid. It dries in a really thin clear coating. People seem to like it. You can find it on the internet. (I should mention that I have no financial interest in the company or the product!)

Thanks Dr. S.

I remain very optimistic and only look at the negative experiences as being learning experiences of what I do not want.

Meanwhile, since that visit, I switched out my diet back to my post surgical plan ( baby food ) and must have jolted something. I've lost 8 lbs. since Thursday!

I will do as you suggested and definately keep you posted.

Thanks once again for being available to field or questions and concerns.

Gratefully yours,

Patty

Update:

Dr. S, from your hotlinks provided I searched and found a surgeon in Florida who TAKES MY INSURANCE and a member of:

American Society of Plastic Surgery

American Society of Aesthetic Plastic Surgery

Florida Society of Plastic Surgery

Broward Society of Plastic Surgery

Broward County Medical Association

Undersea and Hyperbaric Medical Society

American College of Surgeons, FACS – Fellow

American Society of Bariatric Plastic Surgeons

I can't thank you enough for the resource.

> I remain very open minded about surgery with the goal of getting out of pain and stopping the itching I've endured for so long. Having sensation return 'down there' will be another benefit.

Again thanks so much and I will reply back with my progress.

Patty

Hi, Dr. Schulman! I have a couple questions for you. I had Thermage about 6 weeks before all my plastic surgery. I was very happy with the results, but skin seem to be tightening well, especially under my chin. But sense my 7 hour plastic surgery, all my skin looks droopey, fine lines are creeping across my face and any progress I made seems to have been reversed, if not accelerated. Is this normal? Could the pain medication have affected my results? I asked my ps about doing the Thermage before my surgery and he said it should be fine. As you know, Thermage is expensive and I'm wondering if this is a temporary set back or what?

Also, I've been reading about Fraxel repair lasers (CO2 type) and wondering what you think about them? The hype is that they are better than the ablative CO2 lasers because there is less down time, the skin is tightened and the neck can be done? Is this true? I remember you saying that the CO2 laser is the gold standard. I find all of this confusing...

Hi, Dr. Schulman! I have a couple questions for you. I had Thermage about 6 weeks before all my plastic surgery. I was very happy with the results, but skin seem to be tightening well, especially under my chin. But sense my 7 hour plastic surgery, all my skin looks droopey, fine lines are creeping across my face and any progress I made seems to have been reversed, if not accelerated. Is this normal? Could the pain medication have affected my results? I asked my ps about doing the Thermage before my surgery and he said it should be fine. As you know, Thermage is expensive and I'm wondering if this is a temporary set back or what?

Also, I've been reading about Fraxel repair lasers (CO2 type) and wondering what you think about them? The hype is that they are better than the ablative CO2 lasers because there is less down time, the skin is tightened and the neck can be done? Is this true? I remember you saying that the CO2 laser is the gold standard. I find all of this confusing...

Thermage works to tighten the skin, without doing much to the fine lines or wrinkles themselves. I find that Thermage is effective - and by tightening the skin, the lines smooth out. But, I do not agree with Thermage's claim that it only takes 1 treatment. Overall, the improvement is less than they show in the impressive photos. The skin always looks tighter for a time afterwards, than it relaxes a bit. This may be what you are seeing. Also, dehydration will make the lines much more obvious. It is possible that after your surgery you have been a bit dehydrated (which is really common) and this may be the reason things look worse.

Regarding CO2 and Fraxel - These are better for the lines, but will not really tighten the skin. CO2 is the gold standard but requires significant downtime. This is why many companies have developed fractionated systems - less downtime, but need multiple treatments for maybe a little less result. These are also expensive. Fraxel costs about 1500 per session and most people need 3-5 sessions total. CO2 laser also has a tendency to make the skin look a bit "waxy" or have a wierd shine to it. It is also obvious where the laser stopped, such as along the jawline.

New lasers are always coming out, so I caution against jumping on the "next great thing." I think all of them give some improvement, but I am not sure if we are there yet. Still nothing beats a facelift for tightening the skin and getting rid of lines.

Dr. S: Thanks, once again for the clarification. I wish there wasn't such a social stigma to having a face lift. I don't know why, but I'm hesitant to have a face lift. It's one thing if something doesn't look quite right on your body, where clothing can cover it and totally different if something doesn't go right on your face. I guess I'm too close to having just had surgery, but I'm fresh out of courage for now. Hoping for some good alternatives, at least for the time being.

Dr. S: Thanks, once again for the clarification. I wish there wasn't such a social stigma to having a face lift. I don't know why, but I'm hesitant to have a face lift. It's one thing if something doesn't look quite right on your body, where clothing can cover it and totally different if something doesn't go right on your face. I guess I'm too close to having just had surgery, but I'm fresh out of courage for now. Hoping for some good alternatives, at least for the time being.

There is only a social stigma because of the poorly done facelifts of the 1980s - too tight, and "wind-swept". A well done facelift results in a natural, youthful appearance that will only make people talk about you because they are jealous!

Here is my golden tip......try this one at home.......lay flat on you back and look at your face with a hand held mirror. What you see is what you should expect from a well done facelift! Notice how your cheeks are higher and fuller, and your jawline and neck are well defined. But, there is no overpulling of the skin of the face. I do this with everyone of my facelift patients in consultations and I think it is one of the most powerful ways to illustrate modern facelift techniques.

Dr. Schulman: How do you know if your surgeon can execute a well done facelift? My sister-in-law (who is a doctor) had a neck and facelift. The surgery took 10 hours and when she was healed she really didn't look that different. Her neck was less saggy, but it still was quite creased. Her face didn't look symrtrical and her lips, which had fat injections, frankly, looked awful. I've looked at many websites of different doctors before and after pictures and some look great and others do not. I realize that alot of the results are dependent on what the surgeon had to work with. I also realize that no one is going to put their nightmare clients on their website, so really it's hard to know. I've also seen doctors that use fat to fill out the cheeks, chin, lips etc and others that use fillers and implants and others that do none of that. It seems some docs have a more creative take, etc. It's hard to sift through it all. I'm partial to the doc who has put my body back together, but I've been told that faces are a specialty in and of themselves. Well, anyway, I think I've created enough jealousy with my new body for the time being. LOL! Thanks again!

Dr Schulman,

First, thanks for taking time to answer all our questions! This thread is very informative.

I had my lapband in August, 2006. I've lost a little over 100 pounds and seem to have stabalized at 210. Over the last year I've stayed pretty consistent at that weight, gaining and losing the same 5 pounds. I have a rather large apron and a bulge in my upper abdomen that will not go away, no matter what exercises I do! So my first question is, how common is it to do a full tt on someone over 200lbs? Will it cause any further complications? I'm very healthy, low blood pressure, exercise, no diabetes, and a non-smoker.

I had a consult with a ps this week and he recommended a full tummy tuck using an anchor incision to take care of the bulge in the center and remove the apron. He also recommended doing a breast lift at the same time. Is it safe to do the lift and tt at the same time, as he recomended? And what kind of recovery can I expect? I sit at a desk reading books all day for work, and he said it should only be a week or two before I can go back. Will the drains be out before then?

Also, do you know where I can find pictures of tt with the anchor incision? I've found a couple on the web, but not many! It's hard to find info on tt for heavier people, which is frustrating. I really want to have this done, as the results he thinks I can expect sound promising!

Thanks for your help.