1.      How soon after my weight loss can I get plastic surgery done?

Large amounts of weight loss, generally 75 to 100 lbs or greater, will cause significant loose skin on multiple areas of the body. It does not matter whether that amount of weight loss is from dieting, gastric bypass, or lapband surgery, the skin can not shrink back done in most people.

Because body contouring surgery is about removing as much excess skin as possible, one should have maximized their weight loss and proven that this new weight is stable. For some patients, that may be 9 to 12 months. For others, it could be much longer than a year.

The other benefit to waiting until your weight loss is stable is to make sure you are in  a good nutritional state. Weight loss, no matter how it is done, depletes one’s body of vital nutrients and other stores that are needed for the healing of long surgical incisions and extensive wounded tissues.

2.      At what weight should I before I can have body contouring surgery?

Many extreme weight loss patients have a specific target weight in mind. Whether they make it or not depends on a lot of factors and one of those is certainly time. Whether any patient will hit their weight target is unknown. But at some point one will realize a point when their weight will not get any lower. Once one has bounced around at a low weight for awhile, then you can be certain this is where your body will live. Once you are comfortable that you have found this weight, and can keep it, then you are ready for surgery.

3.      What’s the difference between a tummy tuck and a circumferential body lift?

The one body area that bothers all extreme weight loss patients is the abdomen or waistline area. Loose skin is always present in front of, over, and behind the hips. For some patients, a skin overhang is only present in the front. For many others, the skin excess extends around the waistline and across the back, resulting in sagging of the buttocks and posterior thighs as well. These concerns are almost always addressed first in most bariatric plastic surgery treatment plans.

When the excess skin overhang is primarily in the abdominal area, a tummy tuck or abdominoplasty is all that is needed. While it can be a conventional horizontal elliptical excisional pattern, the amount and stretched out quality of the skin may need  a modified pattern to provide optimal tightening. This may require the horizontal cutout to go further back along the waistline or to include a vertical skin wedge resulting in an invert T or anchor closure pattern. (fleur-de-lis tummy ruck)

When the loose skin incorporates the entire waistline, a circumferential or 360 degree cutout is needed. This is known as a circumferential body lift. It is a lot like ‘pulling up your pants’. The scar will run completely around your waistline. In some cases, the front side of the circumferential body lift may include the fleur-de-lis cutout pattern as well.

4.      How can I reshape my saggy breasts…or my manboobs?

One of the most challenging of all body parts to reshape after extreme weight loss is the female breast and the male chest. The female becomes essentially a deflated bag of skin with severe sagging and the nipple often pointed downwards. The male chest also loses volume, although less so than the female, but the chest skin shifts and sags downward with a lower than normal  nipple position.

 The breast often requires a combination of an implant, for volume replacement, and a lift (mastopexy)to reduce the amount of sagging skin and bring the nipple back up to a more central position of the breast mound. This is a difficult operation, from an artistic standpoint, and it often requires two separate surgeries to get the best result.

The sagging chest in the male, while not trying to make a mound like in the female, is complicated by trying to limit scarring. There are no natural creases or folds to hide scars in the flat male chest. Getting the nipple back up on the chest and tightening the skin requires a compromise between the result and the amount of scarring. The chest lift in a man is done differently than a breast lift in a woman.

5.      I hate my ‘batwing’ arms, what can I do about them?

Loose skin in the arms is another common extreme weight loss problem. In the back of the upper arms (triceps area), loose skin and fat hang off and below the humerus bone. This creates a large fold of hanging skin. It often extends into and past the armpit and down into the side of the chest. In some cases, I have seen the skin excess goes past the elbow into the forearm.

The good news is that arm recontouring, known as brachioplasty, is the ‘simplest’ of all body contouring procedures. The arm’s circumferential measurement can be measurably reduced.  Skin and fat is removed longitudinally along the arm and the cut out often takes a right turn into and past the armpit. The bad news is that it does result in a long scar in an unnatural area on the inside of the arm. Scar healing problems are not uncommon in the moist and moveable armpit area.

6.      How bad are the scars from bariatric plastic surgery?

Body contouring after extreme weight loss is about making a trade-off…scars for improved contours. Depending upon the body area, scars tend to turn out somewhat different. Breast and abdominal scars generally look best while arm and thigh scars tend to become wider. Most of these scars are more than just fine or pencil-line in width and some of them will end up becoming hypertrophic or wide due to the tension placed on the wound closure.

Regardless of how the scars may look, there can be a lot of them if multiple body areas are treated. Despite the plethora of this new skin ‘problem’, weight loss patients universally prefer them to their prior ‘sharpee’ body look.

7.      Will insurance cover my skin removal surgeries?

While third-party payors often pay for surgical and non-surgical weight loss treatments, such widespread coverage for body contouring is not so generous. The line between cosmetic and reconstructive procedures for removal of excess skin is a judgment call that does vary amongst different insurers. Ultimately they are looking for functional problems that this skin causes, such as infections, to determine medical necessity for the operation. In general, the most commonly covered procedure is the abdominal panniculectomy or frontal abdominoplasty. The procedures never covered are breast and chest reshaping.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 12:00 - 1:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the very popular topic of weight loss was discussed. With guest, Dr.  Jim Cook Anti-Aging Medicine and Weight Loss Specialist, the many aspects of weight loss management were covered including answering questions from listener e-mails.

Weight loss is a complex topic with numerous causes of weight gain and near endless strategies for its reduction. A comprehensive work-up and laboratory studies should first be done to rule out medical causes such as thyroid disease or low testosterone levels. Caloric and food intake are assessed and managed with an FDA-approved meal replacement program. If necessary, medications are provided including Adipex and HCG (human chorionic gonadropic) sprays. In some cases, human growth hormone (HGH) (by injection)  or crystalline amino acid secretogues may also be used. Lastly, lifestyle changes in activity are assessed including possible prescribed exercise programs.

Because everyone is different, there is no standard program for everyone.  Each patient’s weight loss program is individualized  to their specific needs and goals and how much weight they needor want to lose.  The duration of the program is based on the amount of weight to be lost with an average goal of 2 lbs. per week. One of the most important aspects of the program is long-term weight loss maintenance, a common failure point for most weight loss programs.

Weight Loss and Anti-Aging and Wellness consultations with Dr. Jim Cook can be arranged by calling his Indianapolis Ology Spas facilities at Clarian North office at  317-814-4100 or his Clarian West office at 317-217-2200.

Liposuction is ideally used to reduce spot areas of fat excess in the trunk and neck. In a perfect world, it is done exclusively in patients that have maximized their weight loss through diet and exercise and are at or near their ideal body weight. In reality, not all liposuction patients fit these preoperative criteria. Some patients are looking for more circumferential abdominal and trunk reduction and may be looking for a jumpstart to continue with their lifestyle efforts. Maintenance of body contouring changes and fat reduction is also a concern for many liposuction patients.

Return of fat after liposuction, contrary to what patients would like to believe, is not rare. It is a myth that fat will not return to a body area that has been treated with liposuction, particularly in the trunk area. (abdomen, waistline, flank and back) In my Indianapolis plastic surgery practice, I tell patients that if you can keep your weight stable after liposuction then you will keep the fat from coming back. But if you gain significant weight (greater than 10 lbs), it has to go somewhere.

Managing or continuing with weight loss after liposuction surgery can be done with short-term weight loss medications. I do not prefer to use the typical metabolic-increasing medications that are all derivatives of phenteramine, such as Adipex. While they may be effective, they have more side effects and the risk of dependency. Safer and equally effective medications are Topamax and Zonegran.

Topamax is an anticonvulsant drug that is most well known in the treatment of migraines. It is really a sugar molecule (monosaccharide related to fructose) that has sulfa-like molecules attached. Topamax has a complex mechanism of action but why it works for weight loss is not precisely known. Weight loss is one of its known side effects and is how it has become known for that use. I usually start patients out on 25mg per day for  a few weeks and then increase the dose up to 100mg per day. This is a very low dose compared to how it is used to treat other medical problems. Topamax should not be used in someone who has a known sulfa allergy. Side effects of note include cognitive issues (memory loss) and the formation of renal stones, although the low doses used do not make these a common problem. Patients should be drinking four to six glasses of water a day on any weight loss problem and this is also preventative for kidney stones.

Zonegran is another anticonvulsant drug that also has a sulfa molecule attached to it. Some refer to it as a new and improved Topamax. Sulfa allergies and concerns about the formation of kidney stones are similar. Zonegran is used by neurologists to treat nerve pain and the side effect of weight loss was observed, leading it to be become used for weight loss about five years ago. It is reported to be very effective for sweet cravings, pop drinking and binge eating. I have patients start off with one 25 to 50 mg pill, then increase the dose slowly up to 100 mg every other night for one week and then increase to one every night. The higher the dose, the more the appetite is suppressed.

Both Topamax and Zonegran provide a short-term medication use for continued weight loss after liposuction. Select patients are started on one or the other beginning three weeks after liposuction and given a three month treatment course. Thereafter their continued pharmacologic component of their weight loss program is turned over to a weight loss specialist. Lifestyle changes are an important element after surgery as is the required daily water intake.

This limited pharmacologic approach to augmenting the effects of continued weight loss after liposuction is very helpful for some patients. While plastic surgeons are not weight loss experts, and liposuction is not a weight loss method, body contouring and weight loss/maintenance are nonetheless often intertwined.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Some patients that I see for body contouring ask about diet pill medication and request that I either recommend one or write them a prescription for a pharmaceutical weight loss drug. While I am not a diet doctor per se, I think there are some basic concepts for patients to understand.

If you see any of the infomercials for numerous weight management medications available by a phone call, it is easy to be swayed that these weight-loss aids surely must do something. How could they get on TV and make these claims (in fine print on the screen it always says that these claims have not been evaluated by the FDA…and that the results are not typical) if they really didn’t reduce fat areas? Well, the reality is that they can and do since they are not subject to pharmaceutical oversight by the FDA. (hope is still the greatest sales tool!) What most of them contain are appetite suppressants such as caffeine or ephedra or diuretics that cause temporary weight loss. There is very little true medical evidence that any of these work. And just because they contain ‘natural’ or ‘herbal’ compounds in no way means that they are safe or even effective either. This is evidenced by the recent recall by the FDA of Hydroxycut which had been found to cause some cases of liver damage.

In my Indianapolis plastic surgery practice, I tell my patients this….you didn’t get overweight by taking pills and it is therefore unlikely that you will lose weight by taking pills. There is no magic to losing weight and the effort is certainly not in a pill. The best strategy is eat more nutritious foods and get more exercise…and remember it is a long run plan.

But will prescription weight loss medications work any better? We have an assortment of options available today and there is medical evidence that they do provide some short-term benefit. But the history of prescription weight loss drugs is not good. Many have been ultimately shown to have significant side effects and were ultimately withdrawn. These most notably include amphetamines, PhenFen, and Redux.

Today we have Adipex, Meridia and Xenical as prescription weight loss aids. Only Meridia and Xenical have been approved for longer-term use in significantly obese people, although the safety and effectiveness have not been established for use beyond 2 years. Xenical is also sold in a lower dosage as an over-the-counter drug. (Alli) In general, Xenical and Meridia are moderately effective, leading to an average weight loss of 5 to 22 pounds over a 1-year period, more than what would be expected with non-drug treatments. However, the response to these medications is based on each individual, and some people experience more weight loss than others.The NIH guidelines for treating obesity in adults suggest that if a person does not lose 4 pounds in the first month of taking the drug, it’s likely that it won’t have an effect. And for those for whom the drug does produce weight loss, it’s often not the dramatic fat loss that they often expect.

This does not mean that I think prescription drugs don’t have a role to play in some patients with weight loss. But their use should be short-term and should be used in conjunction with other lifestyle management strategies.After liposuction, for example, I will supplement some patients with up to 3 months of weight loss medication to maximize their gains from the procedure. But there is no reason to continue it beyond that period. I will not start it until they are at least 3 weeks out from surgery when their body is starting to recover from the trauma of the liposuction procedure. But other than that use, patients are best managed by those physicians who can provide them with a more comprehensive medical treatment plan and oversight.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

While all breasts naturally sag as a result of aging, this problem is significantly exaggerated by extreme weight loss. Much like letting air out of a balloon, the breast deflates with weight loss and the breast mound and nipple sag and, in many cases, end up with the breast pointing south and the nipple pointing to the floor. This breast deflation from weight loss creates a condition known as breast ptosis, or the standard plastic surgery term for sagging. (it also occurs in the upper eyelid and is known as lid ptosis)

Understanding breast ptosis and how to classify it is important for all patients to understand, because the degree of breast ptosis determines the appropriate plastic surgery treatment. Does the breast need a lift, a breast implant or both? If it needs a breast lift, what type of breast lift….vertical or extended? These type of treatment decisions are guided completely by whether breast ptosis exists and , if so, to what degree?

Breast ptosis is defined by where the nipple sits relative to the lower breast crease or inframammary fold. (where the underside of the breast meets the rib cage) In a normal youthful breast, the nipple and the entire breast mound sit above the lower breast crease.  Breast ptosis occurs in four degrees of severity as follows; 1^st degree (the nipple sits at the level of the fold), 2^nd degree (the nipple sits below the fold but some breast tissue is still below the nipple, 3^rd degree (the nipple sits below the fold and at the bottom of the breast), and pseudoptosis. (the nipple is above the fold but most of the breast sits below the fold)

Knowing the degree of breast ptosis determines breast reshaping options. For 1^st degree ptosis, a breast implant alone or in conjunction with a small breast lift will work well.  For 2^nd and 3^rd degree ptosis, vertical and extended breast lifts with implants for volume are needed. The lower the nipple sits, the greater the amount of breast lifting that is needed. Breast implants can never lift a nipple that is too low, that is what breast lifts do.

Dr, Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Body contouring surgery can be technically performed on any massive weight loss patient. The important question, however, is whether you can go through the operation safely and heal after surgery with a reasonably low risk of potential complications. (there is no such thing as zero risk of complications in any surgery)

Any patient’s candidacy for body contouring surgery consists of three important issues, your general health, your BMI (body mass index), and your financial preparedness. The first and most important issue is your general health. Do you feel good overall? Are you active and in good nutritional health? Do you have any post-bariatric surgery symptoms such as nausea and vomiting, GI bleeding, or stomach ulcers? Many patients are not truly ready for a major surgery until well after they have achieved their optimal weight gain. Most body contouring surgeries (arms, breasts and neck excluded) should be considered as major and put a lot of stress on your body to not only go through but to heal properly. You must be in a positive nutritional balance to undertake such a task. You will need clearance from your weight loss doctor and blood laboratory studies that look at your blood counts, electrolytes, and protein levels.

The Body Mass Index (BMI) is a good way to determine how effective body contouring surgery will be. Removing loose or excess skin will not be maximally effective if you are still obese. A thick fat layer still persistent under the skin will not allow body contouring surgery to show a good effect. BMI is a number calculated from a person’s weight and height. BMI provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems.The mathematical formulation is difficult to do and one can see their BMI by googling BMI on the internet and using one of the easy calculators which appears on many websites. (for example, http://www.cdc.gov website) BMIs of 30 or lower are most ideal for body contouring surgery. I wouldn’t say that there is an absolute BMI cutoff, but anything over 35 is not ready for those body contouring surgeries that involve the abdomen and thighs unless it is a simple abdominal panniculectomy procedure.

Fiscal preparedness is also an important issue. Most body contouring surgeries are not going to be covered by insurance. Understandably, most patients think that is unfair but there must be a documented medical reason for your insurance carrier to even consider it. (and even then it will be a battle)

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Bariatric, or weight loss surgery, continues to be on the rise with a large portion of the U.S. population officially defined as obese. Gastric bypass surgery, also known as Roux-en-Y, is the most popular surgical method in the U.S. to obtain massive weight loss. While many gastric bypass patients are desirous of plastic surgery to improve their residual body deformities left after the weight loss, less than half actually ever do priamrily due to economic considerations. One very interesting question is that in those patients who do udnergo body contouring surgery, after all the effort and expense, is their weight loss maintained?

 
Dr. Michele Shermak and others from Baltimore at Johns Hopkins attempted to answer this question in a recent article in the June issue of Plastic and Reconstructive Surgery. Over four years, they collected data on 70 patients who lost an average of around 140 lbs and had body contouring surgery after with an average removal of skin and fat of near 13 lbs. Their data showed that gastric bypass patients susbsequently gained around 2 lbs whereas those patients who lost the weight without gastric bypass surgery (diet) gained close to 22 lbs. It should be pointed out that the patient numbers for the diet group were quite low (6) compared to the gastric bypass group. (64) Statistically, however, the difference was still significant.

 
This paper concludes that gastric bypass surgery patients maintain their weight loss better than those patients who lost it by diet alone. I don’t think that this finding is that surprising. The ‘why’ of it undoubtably has to do with ther permanent alteration of nutrient absorption by the bypass. Diet weight loss patients must maintain their weight loss by the mental restriction of food intake, they simply can relape back faster as their ability to absorb nutrients is unaltered. In either case, bariatric plastic surgery produces successful results. Gastric bypass patients are just better at maintaining their investment due to their altered gastrointestinal anatomy.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis