Practice Closure Announcement

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I already had my procedure. Where exactly do I fit here?  Am I a good candidate? What should I watch for?

That’s a fair question.  Unfortunately, there are no two patients that are exactly the same. That being said, many patients tend to need the same types of procedures.

Most patients are candidates for post gastric bypass procedures once they have effectively recovered from their original gastric surgery.  To be a candidate, you must be at least one year out from your gastric procedure AND you need to be stable and plateaued with your weight.  We do not want to take you to surgery if your weight is still going up and down.  We really want to plan for your surgery when your weight stable.  If you think it through, that just makes the most sense.

Most often the gastric bypass team has coordinators that work with us to get you ready and to get you to us.  We interact with these coordinators to get you “optimized” in preparation for the evaluation.  I have to be clear here.  It is OK for you to show up 6 months after your gastric procedure to be educated about the different possible procedures—It is NOT OK for you to undergo the procedures until one year has passed AND you have plateaued.  We really do not want to operate on you and then you lose another 20-30 pounds and be forced to undergo the procedures again.  That would be very unkind to you and would be incredibly costly.

Planning goes a long way.  We are here to help.  So lets chat.  Again, one step at a time.  First lose your weight and be happy and comfortable.  Then, come and see us.

What are the differences between a gastric sleeves and a gastric bypass procedure?

That’s a very interesting question.  Most patients actually do not know the differences.  The older gastric bypass operations were actually mal-absorptive procedures.  That means that the anatomy of a patient was physically altered so that the absorptive surfaces of the GI tract were actually bypassed.  In other words, the place in your gut that would be absorbing food would be bypassed.  If you cannot absorb food, then you cannot gain weight.  These operations unfortunately were plagued with physiological problems, along with dumping syndromes since so much volume was being lost.

As opposed to the older bypass procedures, the newer procedures like the gastric sleeve, actually mechanically make the stomach smaller.  By making the stomach smaller, you have less space to be able to collect food.  Less space translates into less food, and therefore less chance for absorption.  In this way, the effect is not so much physiologic as it is mechanical.  The stomach can only expand a bit to accommodate the food bolus over time and so the patient literally starts to lose weight.  This procedure has been found to be incredibly effective in weight loss.  The patients also have been found to be more ready to undergo additional procedures.  Along with this, their weight loss has been shown to last longer and be more permanent.

What are the types of procedures that I may/might need?

Most often, after massive weight loss, patients end up losing a tremendous amount of fat and body “filler.”  With this in mind, many complain that their body seems to genuinely just deflate.  That is understandable.  But that leaves many with lots of skin excess.  This affects the torso, and central trunk area most.  It also affects the medial thighs, the arms, and the breast areas.  So it is often these areas that are most concerning in regards to the residual effects of massive weight loss.

The trunk and torso are the most common areas that seem to be affected.  Most patients present with lots of extra skin here.  To address this excess skin, there are a few operations that can be considered.  The first is an abdominoplasty or a “tummy tuck.” This tends to address the vertical excess that affects most patients.  The operation resects the skin in the anterior trunk or abdomen.  The loose tissues in the mid aspect of the abdomen are also plicated/brought together.  The abdominoplasty is a good solid procedure and has lots of benefits.  It gets rid of the excess skin in the lower abdomen and it allows a better contour and appreciation of the anterior trunk.  Unfortunately, it is not necessarily the right answer for everyone.  For some patients, the excess skin can be impressive.  It not only affects the anterior trunk, but it also affects the flanks and the back.  In these patients, a traditional abdominoplasty may not be the ideal answer.  In patients with a tremendous amount of skin, even after an abdominoplasty, the patient is often left with residual excess skin at the flanks and in the back.  Most often, these patients return a year or two later dissatisfied with the procedure and its cosmetic results.  This is because they underwent the wrong procedure.  In patients that have a tremendous excess of skin in all of these areas, the belt lipectomy or a circumferential lipectomy is a far better choice.

A circumferential lipectomy or a belt lipectomy is like a tummy tuck that goes all the way around the body.  In this way, the procedure removes all the excess skin from the anterior trunk, the flanks, and the posterior trunk.  It allows the lateral thighs to also be elevated and supported AND it pulls the buttocks area and hind region upwards.  For many patients who have excess skin all the way around, this is the more appropriate/ideal surgical intervention.  In this way, the excess skin from ALL areas of the trunk is removed, not just the front.  This procedure has been tried and is effective and is the one that should be advocated for these types of patients.

Along with a circumferential lipectomy, other procedures are often advocated.  Again, please remember, not every procedure has to be done on every person.  It all depends on the patient and what they want addressed.  Some may want everything addressed; Some may only want the arms or the thighs addressed.  It depends solely on you and what you think will make you happy.  Again, that being said, many patients return after a belt lipectomy and want their arms or their thighs addressed.

A medial thigh lift is another common procedure performed.  It allows us to resect all of the extra skin in the medial thigh area and then to bring the tissues together and give the medial thigh a much-deserved final contour that fits with the rest of the body.  We sometimes use liposuction/lipocontouring as an adjunct.  We NEVER consider lipocontouring by itself in the medial thighs.  Since the medial thigh tissues and skin are so thin and lax, if you simply use liposuction here, the tissues will simply fall apart.  You literally have done nothing except make the tissues and the overall contour look worse.  For this reason, we advocate BOTH skin and fat resection here.  We believe you need to be more aggressive here to end up with a good result.  Again, the liposuction can be used as an adjunct or in addition to the actual skin resection but it cannot and should not be used as the only intervention. Moreover, we use the laser Harmonic scalpel to minimize the swelling.  This makes the incision less problematic and allows the tissues to heal faster.

Along with the medial thigh lift, many patients ask for a brachioplasty or a surgery for their arms.  Those patients that have endured massive weight loss present with a concern about their arm excess skin or what many refer to as “my bat wings.”  This excess skin seems to hang in the arm area and is always a reminder of their previous self.  To address this, we advocate resecting the skin and recontouring the underlying tissues to give the patient a very nice contour.  Again, as with the medial thighs, lipo-contouring can be used as an adjunct.  However, the skin and fatty resection is essential to give the needed final contour.  Without it, the operation seems half finished.  Also, our experience has shown that the use of the harmonic or “laser scalpel” minimizes post-operative swelling and post operative scar formation and scar hypertrophy.

The breasts are the next most often seen procedure.  With massive weight loss, the breasts suffer a great deal of volume loss.  When patients present after their gastric bypass procedure, they often are less bothered by their breasts since unlike the arms, they are not as exposed.  However, in time, the focus does return to them.  To address the laxity of the breasts, we often recommend a breast augmentation along with a vertical or an anchor type of breast lift. The implants allow us to give the breast volume while the lift allows us to resect the lower breast tissue/skin that is simply hanging down and is unsightly.  Often additional adjustments in suture lines are needed to get the breasts to their final form.  These additional adjustments are often done in the office as opposed to in the operating room.

Am I a good candidate?

I believe everyone is a good candidate.  It just depends on what you wish to undergo.  Once you have plateaued in your weight, you need to sit and look at yourself and see what you would like improved.  We can then sit with you and look at the options and see what would be best for you.  Again, remember, no two people are the same.  The plan has to be individualized to you.  You have to have realistic expectations.  Then, we have to sit with you and plan what makes the most sense for you.

When should I come and see you? When should I think about this/these procedures?

Good question.   As I mentioned above, you are always welcome and see us whenever you wish.  This is so that we can meet and make plans.  I would suggest/recommend that you come at the earliest, about 6 months after your gastric surgery.  We can then take the time to educate you in person about the multiple possible procedures.  Does that mean you will need all of them? No.  It simply means that we will educate you about all of them.  Then when a year has passed and your have maximized your weight loss AND your weight has plateaued, then we can seriously sit down and plan what makes sense for your body and what you wish to get.  By doing this, you have control over the situation.  Our job is to help you—Our job is not to take over the control.

What are the procedures that would apply to my abdomen/trunk area?

The most common procedures that apply to the abdomen or the skin excess of the abdomen and trunk are the abdominoplasty procedure, the belt lipectomy procedure and the fleur-de-lys midline addition to the abdominoplasty procedure.  There are other procedures that can be done like the reverse abdominoplasty or the lateral truncal abdominoplasty.  However, these are not as commonly performed.  For most patients, after undergoing gastric surgery and having seen massive weight loss, one of the three procedures I mentioned earlier is most common.

I have already discussed the abdominoplasty and the belt lipectomy procedure at length.  I have not explained the fleur-de-lys midline abdominoplasty.  I will do that now.

The Fleur De Lys (FDL) midline addition to the traditional abdominoplasty is a wonderful procedure that adds much to the original abdominoplasty.  In the more traditional abdominoplasty, the lower abdominal tissues are resected.  This is to address the most often seen “vertical” excess.  This is the tissue that drapes poorly in the lower abdomen and can be resected giving a better overall contour.  In some patients, however, this is not enough.  In some patients, they not only have vertical excess, they are also hampered by “horizontal” excess.  In these patients, a traditional abdominoplasty does a POOR job of a final result.  In these patients, if they undergo a traditional abdominoplasty, they are often left with excess tissues in the midline/core area.  This is easily seen when you can pinch a large amount of extra skin in the mid abdomen, AFTER an abdominoplasty.  In these patients, a fleur-de-lys midline incision allows us the luxury of resecting the extra midline tissues.  This does require a midline incision in addition to the traditional transverse incision.  Using this midline incision, we can resect a tremendous amount of excess skin that would otherwise be left behind.  In some cases, as much as 6-8 inches of extra skin is resected.  That is 6-8 inches of extra skin that would otherwise just sit there and hang.  It is an interesting visual.  Again, this is not indicated for every patient—But it needs to be considered for every patient.

What are the procedures that would apply to my arms?

A brachioplasty or plastic surgery for the arms is an effective intervention for patients after massive weight loss.  In many cases, patients do well and have only this as a detractor since their arms are not hidden.

A brachioplasty allows us to resect the excess skin, or as some call it their “bat wings.”  We often resect the skin and the underlying tissues, using the harmonic laser scalpel.  This allows us the ability to minimize the scar and maximize the recovery. Patients that undergo a resection with a laser scalpel tend to have minimal post-operative swelling and tend to recover extremely fast.

What are the procedures that would apply to my breasts?

There are multiple procedures that apply to the breasts.  The real important thing here is to see what the patient really wants—What is their expectation?  In patients that undergo massive weight loss, the breast tissue often involutes.  This leaves the tissues both lax and empty.  To address this most effectively, we often recommend that patients undergo BOTH a breast augmentation and a lift.  The breast augmentation gives us the ability to put in an implant that gives the patient the FILL that they are missing.  The lift procedure gives us the ability to put the breast tissue back to where it should be to fit the implant and also to give the patient a nice perky new look.  In most cases, there is lots of skin resection.  This is necessary to again make sure that the breast fits the implant and there is not too much skin left over.  If you do not take the skin and simply place an implant, there will be a mismatch of the outside skin and the inside filler.  This would be considered a poor result and so is not recommended.

In some cases, a lift will do just fine.  In other cases, an augmentation does well.  Again, it all depends on the patient’s anatomy and on their expectations and hopes.  Our job is to see what you have and see what you want.  Our task is to get you there in a safe and directed fashion.

What are the procedures that would apply to my neck/face area?

The face and neck areas often shrink back after gastric bypass surgery and are not areas of focus for skin resection procedures.  In a handful of cases, there is some skin excess and that can be addressed with a myriad of different interventions.

For the neck, a neck lift is a possibility.  With this procedure, we tend to bring the muscles of the neck together to get a very nice contoured base at the muscle.  The overlying skin is then stretched to the sides.  The excess skin is resected, leaving behind a nicely contoured look.

Similar to the neck, the face can be addressed with a facelift to resect the extra skin.  The face though is different from the neck.  The face can and in some cases is well addressed simply by injecting fat into the hollowed out areas.  As the bypass procedure has shown, the excess fatty resorption leaves the face hollowed.  This can be addressed by filling the face to correct for the hollowing, AND/OR by resecting the excess skin.  Skin resection of the face by itself is the more older version of the intervention.

This set of possible procedures (fat grafting, neck lift, mid face lift, full face lift) needs to be much more fine-tuned to the patient.  This is a new and exciting area of plastic surgery since before our only option was simply skin resection.  Now with the advent of more purified fat grafting techniques, we can do much more here than previously known.  Again, the exact procedure depends on the patient, their wishes and wants and their expectations.

What is a “staged” procedure? Can I have some of these procedures done together? Is it safe?

That is a great question.  Most procedures take time.  When we are dealing with massive weight loss, and lots of hours of skin resection, we at times are dealing with 7, 8, 9 or ten hours of surgery.  These extended times can put a tremendous burden on the patient, and on the surgical team.  For this reason, we have worked out methods of mixing and matching types of procedures to allow the patient to plan, safely and effectively for their final end product.  For example, if a patient wants to have their breasts, their arms and their legs done, we suggest and recommend completing their breasts first.  We would then have them do their arms and their medial thighs in a second combined, “staged” procedure.  This allows us the patient to undergo the surgery in a shorter time, making it safer for them.  It also allows them time to recover and heal more effectively. Again, this is something that is assessed on case-by-case scenario.

As for safety, the surgical team and the anesthesia team completing the procedures are the best at what they do.  For this same exact reason, if they believe that a procedure or a grouping of procedures places the patient at undue risk, they will have a discussion with the patient to change the procedure or to mix and match the procedure in a different way to ensure the highest safety and the least risk.

Where do you do these more complex procedures?

All of our procedures are completed in the hospital setting.  We provide the best surgical team.  However, without the most effective anesthesia or the most capable nursing, the patient would still be at risk for an adverse outcome.  We currently advocate completing our procedures in the main hospital system, where we can use the full breath of the anesthesia team and the best nursing recovery teams available in the region.

Can I finance these? What arrangements may I make?

That is another great question.  YES.  YOU CAN FINANCE YOUR PROCEDURE.  Each and every one of the local banks has new medical financing tools.  They are very willing to work with you to get your procedures completed.  Since each and every one of them comes out with new deals, I cannot serially recite them here.  The best way to proceed is to come in and meet with us first.  Once we have decided what you need and you agree, we can then have the patient coordinators sit with you and make plans.  They would be the best to approach in regards to details about financing.  They also know of the discounts that may apply to you.  For example, we have discounts for police, and law enforcements.  We also have discounts for medical professionals and health care alliance members.  The hospital system in turn has additional discounts for nurses and medical professionals.  These can all help to make your overall bill less burdensome.  How and in what way they may apply to you depend on your specific situation.  Again, the coordinators are your best bet here.