I f you've undergone a significant weight loss journey, you may be eager to get plastic surgery to address concerns like loose skin.
In this episode, I explain why body lifts are a more comprehensive solution to this issue than tummy tucks alone, and cover the considerations and preparation necessary to ensure a safe and satisfactory end result.
Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I'm your host, Dr. Jason Hall.
Dr. Hall: Bariatric surgery has become incredibly common in the past ten years, and with the increase of bariatric surgery, we're seeing a huge increase, or have seen a huge increase in the need for post-bariatric plastic surgery. One of the most common areas for people to want to have re-contoured after losing 70, 80, 90, over 100 pounds is their abdomen. This show is really dedicated to discussing trunk contouring after bariatric plastic surgery, or what we consider massive weight loss, over 60, 70, 80 pounds no matter what happens, I see a lot of patients who do this on their own with just diet and exercise, which is fantastic. But there are specific needs that patients who have lost that much weight have that your typical tummy tuck liposuction patient doesn't have, and we'll go over what those are here in just a second.
It's important to note that most of these patients who have lost that much weight—and if you're in this category, this is really important—you have specific needs, both surgically and nutritionally, that we have to address to make sure that we get a safe, consistent, good outcome. Let's talk a little bit about what those are. First of all, when we're talking about plastic surgery after significant weight loss, one of the big questions that comes up is one of timing. And really, when is the optimal time to have plastic surgery after losing a significant amount of weight. The impetus is that as soon as you get into that 50, 60-plus pound weight loss, to rush right out and talk about having plastic surgery. You're excited, you've got a lot of extra skin that you really don't like, now that you've lost all that weight. And for a lot of patients, it can be really disconcerting and troublesome that they spend all this time and all his energy and all this money in the case of surgery losing weight, and you almost feel like you'll look worse than you did when you started.
It's really important though, that we respect the natural time course of weight loss and let some of those weight loss changes really kind of settle out. And for a lot of patients, that can take about 18 months after surgery to really have those weight loss changes settle out with time. What tends to happen—and this is especially the case in patients who have had gastric bypass surgery—is that you'll see a huge drop in weight over the course of the first six months, then level out for a few months. And then between nine months and a year you'll see another drop-off. We want to get through that second lower plateau before we start doing surgery because the last thing that you want to do is have surgery and then lose another significant amount of weight.
Because you will have gone through all of that and then you end up, the skin that we tighten gets loose again. And so, you really want to avoid that. For that reason, it's really important that we make sure that you have plateaued out, that you've been at a stable weight for about six months before we look to do any skin removal, skin tightening, any of that. So, we want to see your weight stable for about six months. Now, we can cheat a little bit and do it a little bit earlier, but six months is the general rule of a stable weight, if you've been losing weight yourself, or that equates to about 18 months if you've had weight loss surgery.
The other thing that is really important to consider when we're talking about patients who have lost a lot of weight is to make sure that your nutrition is good. And you can think about nutrition as almost being the building blocks. You know, I use construction metaphors a lot, so you have to have the bricks and mortar to be able to heal, and your nutrition is really what those bricks and mortar are. A lot of weight loss procedures, your gastric bypass, your duodenal switch, those are malabsorptive procedures. So essentially, what it is is controlled starvation is how you're losing weight.
Now, the gastric sleeve is a little bit different. That's more of a restrictive procedure, so we're making the area where food can sit in your stomach smaller so you can't eat as much, but you're still using all of your small intestine to absorb nutrients so it's not a malabsorptive or a malnutrition procedure. But it's still very important that we make sure that your nutrition is optimized before we do surgery. Because when we're doing these, patients see the incision on the outside, you know, you the patient, you look on the website, you look at the body lift, you look at breast surgery, and you see the incision on the outside, you don't see all the work that happens underneath the skin. And there's a huge surface area that needs to heal. We need your body to be in an optimal nutritional state in order for that to happen to prevent us from having healing complications. And we'll get into what some of those are here in a minute.
So, we like to make sure that you're nutritionally optimized. The numbers that we look for, first, we want to make sure your protein levels, your albumin levels, which is a blood protein, are within the normal range. The other one we look at is the prealbumin level, and that is a marker of kind of shorter-term nutrition in your albumin. So, we need to make sure that both of those are normal and that your blood counts are normal because anemia is another thing we often see in some of these some patients who have had weight loss surgery, and we want to make sure that all those things are corrected before we do surgery.
So, we check those during our pre-surgical planning phase. That kind of brings us to the surgery itself. You know, we see a lot of patients and we try and do a lot of education on the front-end because most patients see themselves from the front. And they see a lot of excess skin, they see creases in the skin that they don't like and want those removed. So, they call and say, “Look, I really needed a tummy tuck.”
You know, if they're just looking around on the internet, they see pictures of tummy tucks, that's what they hear, that's one of the most popular and common cosmetic plastic surgery procedures out there now. And so, you end up thinking that's what you need. And for most patients who have lost a lot of weight, they have laxity of their skin and loose skin that goes all the way around. It's just harder to see in the sides and in the back.
The way that our bodies are set up, the way that God put us together, is we've got fascial connections. So, we've got connections between the skin and the muscle fascia, which there's a band right above your belly button, sometimes at your belly button, and then there's a band kind of right at the top of your pubic bone. And what those fascial bands do is they keep skin from descending too far south. That's what creates the rolls and the folds and the things that people see that they don't like. Those fascial connections stop, for large part, on your sides, and you have smaller ones in your lower back, but they're not as dense and they're not as visible as the ones in the front, and so people kind of ignore that area unless they're really looking.
The lack of dense fascial connection to the skin also means that skin's not going to stop; once it gets loose, it's just going to kind of go south. And so, you know, we have had patients that have only half-jokingly described or they feel like they're melting, that their outer thighs, their butt just kind of melt into their legs. And that's where a lot of that extra skin goes after significant weight loss in your thighs and in your backside. You know, in order to get a good result, we really have to have a surgery that's going to address not only the excess in the front but the excess on the sides and in the back. And that surgery is something known as body lift or a belt lipectomy, there are a number of different names for it.
Body lift I feel is the best descriptor a non-medical person is going to understand. And what that is is a tummy tuck that goes all the way around. And you can see results and what that looks like. You've got a scar that goes all the way around, and that scar, just like tummy tuck scars, I try very, very hard to make sure that scar sits low, sits hidden in a panty line or bathing suit line so that it's not visible. We need to make that scar so that we can remove the excess that goes all the way around.
As you can imagine, body lift surgery is more involved than tummy tuck surgery, certainly. It takes longer, the recovery is a little bit more challenging but is still a very, very high-impact procedure in terms of patient satisfaction. If you've listened to the abdominoplasty or tummy tuck podcast, I talked about how, you know, with a tummy tuck, we're really doing three things: we're removing excess skin, we're removing excess fat, and we're tightening the muscles. With body lift surgery, we're really doing the same things, the same muscle tightening, the same rectus plication that we do with abdominoplasty surgery, we do with body lift surgery. The same anesthesia, you know, using tap blocks to help deaden the abdominal wall muscles I use before any body lift surgery because it's the muscle work that really causes a lot of the discomfort from these surgeries.
And so, using that tap block before surgery even starts really helps you get a leg up and get a jump on your recovery so you don't feel like you need to sit in bed because that ultimately is the cause of a lot of the significant postoperative complications that we can see. Other adjunctive procedures or additional procedures that we can use with body lift surgery are buttocks augmentations, you know, a lot of people lose a significant amount of volume in their buttocks, so buttock augmentation is sometimes combined with body lift surgery for patients who have that as a problem area. And we can do that either using liposuction with your traditional injectable buttocks augmentations or there are also technique where we can use the skin and fat that we're going to remove and use that to help create and shape a buttock when we're doing that surgery.
So, that adds another level of complexity, adds more time in the operating room, and complicates recovery positioning a little bit, but is one of those additional procedures that is sometimes added to body lift surgery. In my practice, you know, I'm fortunate enough to have our fantastic surgery center just right below us here in the building where this is all we do is cosmetic plastic surgery, day in and day out, so body lift surgery in my practice is an outpatient procedure. Some surgeons do this in the hospital, they admit patients overnight. In my practice, you know, where safety and patient experience is really paramount, you don't want to spend a night in hospital. This is something that we've kind of worked with our anesthesia team, the surgical techniques that I use, make it such that, you know, blood loss is minimized, fluid shifts are minimized, and so sending patients home to recover in their own home is really safe and is, you know, patients would much rather be at home on their own couch, sleeping in their own bed than sleeping in some hospital bed with the beeps and the nurses checking every two hours, keeping you awake while you're there.
In the early days of body lift surgery, it wasn't uncommon for patients to need blood transfusions in my practice. Knock on wood that is unheard of, I think. In 12 years I haven't ever transfused a patient for an elective body lift surgery. Those two things don't seem to jibe in my head, needing a blood transfusion with the risks of that with cosmetic plastic surgery. They just don't go together.
Recovery from body lift surgery is something that patients typically will start to research and get a little bit hesitant about. The recovery itself in the first couple of days is a little bit more difficult than an abdominoplasty in that you have an incision that goes all the way around, so you're stuck in, kind of, positional limbo. You can't really lay flat because then you put too much pressure on your abdominal muscles and your incision up front. You can't really sit straight up because then you put too much pressure on your incision in the back. So, you're stuck in this kind of beach chair limbo position where you're kind of half reclining.
It takes a little bit of trial and error to figure out how to go from that to standing up, but you know, you do that once or twice, you figure it out. And then really within three days, four days, you're able to stand upright, walk around, and can kind of get around relatively normally. You're still going to have some discomfort in your abdomen, still going to feel like walking a little hunched over for another day or two, but the real positional limbo is typically over after, you know, 72 hours or so. Patients with body lifts do have drains. I have a video on that; check it out.
And you know, I kind of go through the ins and outs of JP drains. Those are there to help prevent seroma formation under your skin, and that's probably one of the most common complications of body lift surgery is seroma formation. And seroma formation, you know, think about when you skin your knee and it's kind of disgusting and oozy and everything until a scab forms. The inside of your body does the same thing. When I take off that extra skin, pull the remaining skin down, and secure it into place, there is raw surface area on the inside, both on top of your muscles and under your skin, that's trying to heal, and the way that your body does that is by creating some fluid. And if that fluid builds up and doesn't get out, then those layers kind of glide together and don't stick and you can form a seroma or fluid cavity.
So, those drains are placed to help prevent that seroma formation, get that fluid out in that early healing phase so things can stick, then we can remove those. Typically with a body lift, that means about a week, sometimes a couple more days. Everybody is a little bit different, but you can count on at least a week of having usually two, maybe three drains to help get that fluid out. That kind of leads to other complications in body lift surgery. I said seroma is probably the most common.
There are—can have some minor wound healing problems, sutures that kind of rub through the incision line, scars that don't heal just like we like them. That's, you know, one reason why we check your nutrition is we want your scars to heal nicely as well, not only the inside but the outside. And those are that kind of the more common. You know, they're a pain in the butt—I call them problems with a small p—that we can deal with here in the office. The big problems that we do everything that we can to try and avoid, one is hematoma formation.
The body lift population is at higher risk for hematoma formation because the vessels that that supply the skin, that we actually have to divide, to remove it tend to be larger caliber, they're bigger around than in patients who just have some extra skin after pregnancy, you know, the tummy tuck patient population. They dilated when you were bigger, and then when you get smaller, those vessels stay about the same size. And there—I've seen blood vessels underneath the skin that have to divide to remove the extra skin that are almost as big around as my pinky finger. And you can imagine if one of those starts to bleed, it can be a big problem. And that's why I'm really fastidious and really careful with those vessels.
You know, normally, we can just kind of use our electric cautery machine to kind of what we call buzzing these, to cauterize them and heat seal them, but in patients who have had a body lift, it's not unc—actually it's very common for me to actually sew those vessels to keep them from bleeding later to prevent hematoma formation after surgery because that can be a big problem. That can cause hospital admissions, blood transfusions, things like that, which we want to avoid. So, that's kind of how we prevent that. The other one that is really problematic in the post-bariatric surgery population are deep venous thrombosis and pulmonary embolism. You know, these are dreaded complications in any cosmetic surgery and can be more problematic and more common in the bariatric patient population.
This is where you hear about people talking about getting blood clots in their legs. You can get those in your legs and then if they break off and go to your lungs, that can be a fatal problem. And so, you know, we have screening tools that we use for every surgery. A lot of patients who have body lifts meet criteria to have a blood thinner injection before surgery to prevent those clotting complications. And some patients even go home on a blood thinner.
You know, that's not common, but out of the interest of safety, there are some patients that need it. The way that we prevent that, one, is just like I talked about, our preoperative screening. The other is what you do and what we tell you to do after surgery is walk early. Get up the day of surgery and move around. That's the best way to prevent those blood clots from forming is keep yourself moving, keep that circulation in your legs moving.
One of the things that we have seen—‘we' meaning our group of plastic surgeons—over the years of doing this have seen as a predictor of complications after surgery is preoperative body mass index or BMI. And if you've been through the weight loss surgery, you've been on that weight loss surgery treadmill, BMI is a number that you're used to hearing about. What that is is—for those of you who haven't or have been doing this on your own—it is an index between your height and your weight. What we call a normal BMI is 25, which is unfortunately fairly uncommon these days. A BMI of 30 classifies someone as being clinically obese.
And that is where, with thousands and thousands of patients, we've seen that at a BMI of 30, the complications from—the serious complications, clotting problems, dying, hematomas—those complications take a hockey stick rise at a BMI of 30, at and above a BMI of 30. And so, my cut-off for doing body lift surgery or any post-bariatric operation is at a BMI of 30. And so, if you're above that threshold, when we're talking about surgery and planning for surgery, we need to work with you, we need to work with your nutritionist if you've been working with one with your weight loss surgery program, or help find and refer you to one of the nutritionists that we work with frequently to help get you below that threshold so that we can bring the risk of complications down before we do anything. As I said before, you know, safety is paramount, and so any and everything that we can do to ensure a safe surgery we'll do, and that includes helping get your BMI down beforehand.
There are a bunch of other post-bariatric operations that we can talk about, and usually, you know, when I sit down with a patient who's been through bariatric surgery, we end up touching on all the other areas that they're interested in. Usually, that includes breasts, which means usually a lift with an implant, arms, thighs, face, and neck. Because all of those areas, when they deflate, that skin has been stretched to a point where it's not going to contract at all. And so, it's important that we kind of address all of those areas over time. But because of the size and nature of body lift surgery itself, we can't address any of those other things at the time we do a body lift; those are all addressed it at a separate time.
And the typical scenario is body lift is a standalone procedure, breast surgery and arm surgery typically goes together, thigh lift surgery is typically a standalone operation, and then facial surgery—you know, facelift, necklift, volume enhancement—is typically a standalone procedure itself. And so, we try and kind of batch as many things together as we can to save recovery time, to save operating room time, and just make everybody's life easier and make this less involved. Sequencing of those surgeries has to be done kind of in a way that is convenient for you, the patient, and safe.
That kind of brings me to what comes first. And that really is up to you. That is a discussion that we have at your consultation. And most patients who have lost a lot of weight, their stomach is their biggest concern. I've seen a number of women whose breasts and arms were their biggest concern and we've addressed those first. Occasionally, I'll have a patient whose face and neck is her biggest concern, and we'll address that first.
But it is really a personal decision, not necessarily a medical decision. It's just something that we have to kind of talk through and helps if, knowing what is out there that we can do, if you kind of have a priority list when we sit down to talk so that we can address things in a way that you'd like to get them done, but then in a way that safe and makes sense from a surgical standpoint.
I hope this was helpful to anybody out there who has undergone a significant weight loss, whether it is on your own or surgically. I do want to say congratulations. That is a significant journey; it's a significant accomplishment. If there are any questions that we didn't answer in this show, you can shoot me an email email@example.com. Leave a comment below. I hope you enjoyed this podcast and we will see you again soon.
Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.