We all have big changes in our lives that are more or less a second chance.
-Harrison Ford, actor, from Harrison Ford: Imperfect Hero by Garry Jenkins
After all your hard work, you've finally reached your goal weight. Or perhaps you've reached a final plateau that is close enough to what you wanted, and now you're left with a bunch of extra skin. In the last chapter, we looked in detail at skin and how it's affected by weight gain and weight loss.
Now that you've lost weight, and your skin isn't what you'd like it to be, you're probably asking yourself, "Should I have plastic surgery?" For many patients the answer frequently goes something like this: "Well, I've come this far, I might as well go all the way." Others are more reluctant, either because of cost or risk. Depending on how noticeable that extra skin is, you may not want to bother. With time there may be some additional shrinkage, but it is very difficult to know to what degree. This chapter is intended to "tie everything up"pun clearly intended.
If you are considering plastic surgery, it is important that you know all the facts. What is possible? What isn't possible? What exactly does plastic surgery entail? When is a good time to have it? What are the risks? Who should you go to? Let's start with the last question first.
Choosing a Plastic Surgeon
We usually think of the word "plastic" as referring to a synthetic material that is chemically produced specifically to replace a natural material like wood or iron. But in surgery the word "plastic" is an adjective defined in Taber's Cyclopedic Medical Dictionary as "capable of being molded." And "plastic surgery" is defined as "surgery for the restoration, repair, or reconstruction of body structures."
A plastic surgeon is a doctor who has completed additional training specifically in the performance of these procedures. He or she is a specialist in the field. However, not all plastic surgeons routinely perform recontouring procedures specifically for patients following major weight loss. So, in addition to finding a surgeon who is certified by the American Board of Plastic Surgery, you should also inquire about specific experience in the area of body contouring following weight loss.
It is common for patients to choose a plastic surgeon based on the recommendation of a friend who has had one or more procedures by that particular surgeon. You can also ask your primary doctor or the surgeon who performed your band operation whom they would recommend. Having someone you trust make a recommendation can add significantly to your confidence, even before you meet the surgeon. But, ultimately, the decision about which doctor you have do your surgery should be totally up to you, and based on your own assessment.
When you go in for an initial consultation with a plastic surgeon, the first thing you should find out is how much experience the surgeon has with body contouring after weight loss. There are many very talented plastic surgeons who have great reputations for doing various cosmetic operations but who may not be familiar with the special circumstances surrounding your particular situation. What you should be looking for is someone who takes a special interest in this area. That doesn't necessarily mean that's all they do, but your results are likely to be better with someone who has some experience.
Don't just dive into all the things you want done. Take some time to get acquainted and see if this is someone you can relate to and who seems genuinely to care about you. The surgeon will want to understand your entire medical history, not just your weight loss, and he or she will want to take a careful look at you before making any recommendations.
You probably won't have to ask them to show you photographs. Most plastic surgeons have numerous before and after photos of patients whom they have operated on. Make sure they are showing you their results, not those out of a textbook or some other surgeon's experience. Also, realize that it is only natural for the surgeon to show you his or her best work, so you can anticipate seeing some really spectacular results. Not every patient ends up with spectacular results. Ask to see pictures of what the surgeon considers average results, and even some poor results. You need to be prepared for all the possibilities.
If there was ever a time for a second opinion, this is it. Many plastic surgeons offer free initial evaluations, but even if you have to pay for two or three consultations, it will be worth it if they ultimately help you make the right choice. Remember, this is like hiring someone to design and remodel your home. Take your time and get a few bids. If at all possible, get some references and telephone them. Understand that the surgeon is likely to give you only the names of patients who are very satisfied with their results. Even so, you can get some very useful insights into what you can expect by asking questions about the doctor's attention to detail, as well as the attitude and responsiveness of the staff.
Checklist: Looking for a Plastic Surgeon
✓ Ask doctors you know for referrals.
✓ Ask for referrals from other patients.
✓ Get two or three surgeons to talk to.
✓ Take your time and get a few bids. This is like remodeling your house. You want to feel knowledgeable and comfortable with the surgeon you choose.
✓ Does the surgeon care about you and your medical history?
✓ Do you get the feeling that they have your interests at heart? Are they in a hurry for you to get started? (That is not a good sign.)
✓ Does the surgeon have experience with body contouring after weight loss?
✓ Ask to see before and after photos, not only of great outcomes but also of average and poor outcomes. You need to be prepared for all the possibilities.
✓ Are there patients you can talk to?
✓ What is the doctor's attitude and responsiveness, as well as the responsiveness of the staff?
When Should I Start Plastic Surgery?
Speaking of time, the timing of any plastic surgery can be critical, so make sure that you and the surgeon agree on an appropriate time to begin the makeover process. I have had some patients who were extremely impatient and wanted to have something done long before they had finished losing weight. Most of the time taking that approach ends up being wasteful and creates less than satisfactory results.
It's generally a good idea to wait six months to a year after you have achieved your maximum weight loss (meaning you've stopped losing weight for that long) before having plastic surgery. Any sooner and you run the risk that you may lose more weight, which might require another operation to trim away additional excess skin. You also want to make sure that your weight is stable, since some people regain some of the weight they have lost within the first year. You could be all neatly repackaged only to start the stretching process over again. And scar tissue doesn't stretch as well as the initial skin did.
Be Prepared for Scars
It is important to recognize that there will be scars. There is no such thing as scar-free surgery. Essentially, what you are doing with plastic surgery is trading extra skin for scars. Now, some procedures have fewer noticeable scars than other, and some surgeons seem to have better outcomes than others, but they will all tell you that it is not possible to predict exactly what your scars will look like once the incisions have healed.
As a rule, body contouring requires the removal of huge pieces of skin, and therefore long scars. In some cases these can be partially hidden, but you will always be able to see them. Be fully prepared for what they are likely to look like before you go ahead.
What to Lift and What to Leave
Some patients want only limited changes, such as a partial face lift or removal of their excess upper-arm skin. Others may want multiple areas lifted and others enhanced. It is critical that you talk candidly with the surgeon about what you would like. There is nothing wrong with creating a list of what you consider "must do's," "might do's," and "wish I could do's."
Don't be shy to list everything you can think of; it doesn't mean you are going to do any of it at this point. It will give the surgeon a clear understanding of what your priorities are, so he or she can develop a plan that meets your needs as efficiently as possible. You may even discover that one or more of the procedures on your wish list are easier to get than you thought.
Once you have decided on precisely what you want, you and the surgeon will need to agree on the timing and sequencing, if multiple procedures are involved. You may want to have several different procedures performed at the same time, either to save money or because you're in a hurry, or both. And some procedures are more easily combined than others.
A prudent plastic surgeon will not recommend initiating your plastic surgery plan until your weight has been stable for at least six months. He or she will also recommend which procedures you can safely combine along with an appropriate interval between procedures, often several months. This is necessary to give you time to recover from the stress of the operation and heal the incisions. Just remember that these procedures are much like your original bariatric surgery, totally elective. Make sure that both you and your surgeon are comfortable with the strategy before you go with it.
The Procedures
Body contouring involves more than just lopping off some hanging skin and sewing you back up. The process takes on somewhat of an artistic air, with you as the lump of clay and the plastic surgeon as the sculptor. The objective is to reshape your skin to match the original appearance as closely as possible.
Some parts are easier than others, but it is possible to modify virtually every part. Doing so can also result in the loss of several more pounds, but don't confuse this side benefit of plastic surgery with your overall weight-loss program. It's simply a bonus, not a substitute for diet and exercise.
Face and Neck
Some of the most dramatic results are obtained by lifting the sagging skin of the face and neck. These are areas that are always visible, so eliminating those jowls, the gobbler neck, or the bags under your eyes can make you look years younger. These procedures can also be done with very little visible scarring, since the incisions can usually be hidden in the hairline or behind the line of the jaw. Not all facelifts are they same. Be sure that you and the surgeon have agreed on what will and what won't be lifted. You may or may not need a complete makeover.
There is a procedure called a "thread lift" that has been widely publicized as an inexpensive and quick alternative to a formal facelift. It involves using a series of sutures that are threaded through the skin and are then secured to other tissues higher up in the face to suspend the sagging skin with very minimal incisions. In theory it sounds good, but it is usually only recommended for young people looking for a minor lift. The results can be somewhat unpredictable, and the lift it provides typically doesn't last as long as a more traditional facelift.
Arms
One of the more noticeable and annoying excess skin problems, especially for women who lose a large amount of weight, is the upper arm area. The appearance is commonly called "bat wings" because when the arms are extended straight out, the skin droops down dramatically from the elbows back toward the chest. For many women this is the first thing they have addressed with plastic surgery, because the problem is obvious when they wear anything that is short sleeve or sleeveless. You have just lost a bunch of weight and are buying new clothes that you want to flatter that new body, only to have these "bat wings" visible as a reminder of your recent past. There is really no way to hide them other than long sleeves, and even then the excess skin takes up considerable space inside the garment, making it feel too tight in the arms.
Addressing the upper arm skin is not as technically difficult as some of the other areas of the body, but it does leave visible scars down the arms. There are some surgeons who claim to get good results by pulling all the skin up into the arm pit and thus hiding the scar, and that may be possible if the problem is relatively minor to start with. When large amounts of skin need to be removed, it probably won't work nearly as well as an incision down the length of the upper arm.
Most patients are thrilled with their new, slimmer arms and don't seem to mind the scars, but be sure to look closely at the pictures you are shown before having this procedure. Make sure that you are comfortable with the location and extent of the scars, because you will see them every day for the rest of your life.
Janet's Story
(Left) Janet, pre-op, over 300 pounds.
(Right) Janet, three years post-op, about 170 pounds.
I think my starting weight was 289 when I first saw Dr. Sewell, and I'm 5 feet, 6 inches. I'd lost about 30 pounds on my own, so my top weight was well over 300 pounds. I'd tried everything else, and all of the diets worked to a point. I'm not saying that they're bad for anyone else. Everyone is dif ferent, and different things work for other people. But while people can argue that obesity is a head thing all they want, I was always hungry. I'd try starving myself and I'd get nauseated. And I didn't make good choices when I chose food.
When I started researching band surgery all I heard about was gastric bypass, and I thought there was no way I'd allow my insides to be rerouted. I went to another doctor's seminar and heard about the band. I was married at the time and my husband was leery, so I let it drop. Later, when I was getting divorced, I e-mailed my ex, said this is what I want to do, and this is what I need from you to do it. He agreed to help.
Dr. Sewell put my band in on April 2, 2003, and by early June I'd lost 40 pounds. I've lost about 120 pounds altogether in the four years I've had the band.
I've always been extremely active. I used to shock people, because people would be surprised what I did. I hiked and did a lot of things. Even so, I notice a difference in my energy now that I have more of it and I feel better.
The second biggest thing I noticed was the change in people's attitudes. I was always friendly and outgoing, but a lot of people seemed to think that I suddenly got a brain. My opinions seem more valuable, and it really kind of irritated me because it's so unfair. But I notice now that instead of having to pretend to be confident and assured, I am confident and assured. The weight loss gave me a freedom. I feel good about what I'm doing, and I feel good about my life. It's not a compelling feeling anymore that I have to make them feel good and I have to make them understand what I'm doing. Now I can let them not understand. I still go into a store to buy clothes and I walk to the women's department first instead of the misses. I have to correct myself. I was in 26/28, and now I'm in a 10/12. I have some stretchy jeans that are 8/10 and some jeans that are 14, so a lot depends on the brand.
I'm a nurse, and I work two jobs because my parents are in assisted living I need the income. I do phone triage for a hospital. When I applied for the second job at the high school, I realized I probably wouldn't have gotten the job before because of my weight. But not only did I get the job but I'm also taking a trip to Europe this summer with the foreign language club at the school. We're going to Spain, Germany, and France, and we'll be gone for two weeks. I feel comfortable doing this trip knowing that I'll not have to wedge into a little, narrow seat in the plane.
In fact, I'm more comfortable everywhere. I go into a movie theater and sit down and don't have to worry about wedging people out beside me. I can bend straight over to tie my shoes. I can bend over and reach something under a piece of furniture, instead of getting down on the floor and crawling over to pick something up. All those little things mean more to me than anything. It's still amazing to me.
My band slipped once, and I had to have it redone. I knew something was wrong because I had such bad reflux. I'd always had some reflux, but this was very tough. I didn't go to Dr. Sewell, though, because I didn't feel it was that important. Then I ate a small salad and it went down, but I kept burping a lot. The burping was nauseating, and it was foul tasting. I was getting sick to my stomach, and I threw up rotted lettuce two days later. And that's when I felt I needed to get it checked out. It was so foul tasting that I was still gagging when I went to see Dr. Sewell, and the smell was still in my nose. He did the upper GI and saw that the band had slipped.
The repair was easy, and I was in the hospital a day. I scheduled it so I had several days off. When I first woke up I started taking fluids again. I thought, "This stuff is going down easy." The most I've ever carried in my band is 1.5ccs. But this time, when it was time for a fill, I had him put only 0.5cc in it. And that has been just enough to keep me honest. If I try to eat too much the band is like a fist grabbing me and going, "No you don't." I wish they'd had this 30 years ago. But on the other hand, I wouldn't try to talk anyone else into it. To be honest, it's a good and bad thing. You have to be ready to do this or you won't be successful.
I have an overweight friend whose husband is encouraging her to get a band. But I told her I wouldn't try to talk her into it. She was shocked and asked why. I said that all you ever talk about are the potential problems and how much you'll miss the food you love. That tells me you're not ready.
There are times, I'd give my eye teeth to have a huge steak and baked potato. Steak now is out of the question. No matter how much I chew it, it's like it gets bigger in my mouth. And beef is very heavy on my stomach. But would I have the weight back so I could enjoy those foods again? No way. Food used to be extremely important to me. You don't totally lose that when you've been there so long, but it doesn't take much thought for me to make the choice I want, and that's to be smaller.
Some people don't seem to care, and find ways to eat around the band. Those people are not going to succeed. Someone else I know got a band, and they told me they didn't want to exercise and never intended to exercise. They said they'd paid enough for the band that they didn't feel they should have to do anything more. I answered that if I'd known they felt that way, I would have suggested they think about doing something besides a band.
I think some people I know are internally really angry with me for losing weight. One of my overweight friends said to me that when I talk about the band it irritates her and that it "makes me just hate you." It isn't like I talk about the band all the time. I wait until someone asks me before I comment. I've heard that when you're overweight you lose friends because you're overweight. When you lose the weight and get thin, you find out which of your friends are real friends, because the ones who leave never were.
I've had two plastic surgeries. My primary care physician said I'm too old to be doing all this plastic surgery. But I had my arms done, and at the same time the plastic surgeon did a lateral chest incision halfway under each breast to give me a mini lift. I don't want breast implants. The latest I had took skin from all the way around me at the waist and gave me a tummy tuck along with a butt and thigh lift. On the plastic surgery, I was determined to make sure I did it right. I feel like I've had good results, but someone younger would have better results because they're younger. I lost weight with each surgery, but I lost 13 to 15 pounds with surgery around my waist alone.
My grown son has been transferred back with his job, so he lives near me, and now I have six grandchildren nearby. And I can keep up with those grandchildren. With the weight loss, so many good things have happened, I wonder when it'll stop. I'm extremely thankful. I believe it was divine intervention.
Breasts
This is probably the most subjective of all areas of body contouring. What exactly is a normal breast? Following weight loss, most women find their breasts sagging. That is because the average breast is composed of more than 50 percent fat, and in obese women that number may be closer to 90 percent. So when you lose a lot of weight, the breast is one of those places where it shows the most.
To address the problem of sagging breasts isn't just a matter of removing skin. Any breast lift by necessity must also include the repositioning of the nipple-areola, so that the breast looks normal. This usually requires a "keyhole" shaped incision with removal of the excess skin from the bottom of the breast: the nipple area is moved up, and the skin closed beneath it. This creates a scar that goes completely around the areola (the dark skin around he nipple) and then extends straight down to the bottom of the breast and then under the entire breast. Because the scars are on the bottom of the breast, they are not generally visible even in a low-cut blouse, but typically they will be quite obvious to you every time you shower.
Depending on how much of your breast tissue has disappeared with weight loss, some women actually have their breasts enhanced with implants. This can be done at the same time as the lift and may greatly improve the overall appearance. But again, this is an extremely subjective issue, and you should do what feels right to you.
Men who lose a large amount of weight may also be plagued with sagging skin on their chest and around their breasts. The same type of procedure can be performed with only minor modifications to help create a more chiseled male figure.
Abdomen and Trunk
Most obese people carry much of their weight in and around their waistline. This often leads to a large, protuberant abdomen that hangs over the beltline, called an abdominal pannus, or "apron." Even without weight loss, some people opt to have this large fatty apron surgically removed with a procedure called a panniculectomy. That is most often done to help heal the skin under the pannus, or in conjunction with other internal abdominal operations simply to get it out of the way. The procedure doesn't usually lead to the kind of cosmetic result most patients are looking for after weight-loss surgery.
The "tummy tuck," otherwise known as an abdominoplasty, is the operation most commonly performed to get rid of that excess skin on the abdomen. I often chuckle when patients ask why I won't do just a little tummy tuck for them "while I'm in there." First, I don't do that procedure, and second, there's no such thing as a little tummy tuck. This is usually a major undertaking that may take several hours.
This procedure recontours the entire abdomen by removing the skin of the pannus, repositioning the belly button (umbilicus) back up to the middle of the abdomen, and sometimes even involves tightening the abdominal muscles. The scars can generally be hidden well below the waistline, but there will be a circular scar around the belly button.
If the front of your abdomen is the only concern, a standard abdominoplasty may be all you need. However, if your skin is sagging all the way around your torso, it may not be enough. The entire trunk area can be addressed with a procedure that extends all the way around, called a circumferential body lift or belt lipectomy. You can think of it as an extended tummy tuck that removes excess skin from your flanks and back and even lifts the skin of the buttocks and the outer aspects of the thighs. This is a big operation and should probably not be combined with other procedures.
Legs
The body lift may address the outer part of the upper thighs, but it doesn't do anything for all that extra skin hanging from the inner thigh. The approach to this area is much like that for the upper arm, and not uncommonly plastic surgeons will recommend they be addressed at the same time. The incisions and ultimately the scars will extend down the inner thigh from the groin area to near the knee. One of the most pleasant results of this operation can be simply that your thighs don't rub together all the time, eliminating the constant chafing of your skin in that sensitive area.
Minimizing the Scars
For patients who have lost a lot of weight, these plastic procedures are a tradeoff-excess skin for permanent scars. No matter what you may have heard or want to believe, scars don't go away. But some are very obvious, while others are hardly noticeable. What is it that makes the difference? There is no quick answer to this question because the appearance of each individual scar depends on a number of factors. Some are controllable and some are not.
If the scar looks great, it is tempting to give the surgeon all the credit, and certainly his or her skill and experience play an important role. But scar tissue is part of your body's healing response to any injury. Some people naturally create dense, thick scars, yet others seem to heal with minimal visible scars. The same surgeon, performing the same procedure on two different patients, may be hailed as a hero by one, while the other may think the surgeon must have done something wrong based solely on the appearance of the scars.
There are some important things that the surgeon can do to minimize scarring, and they have to do with the direction of the incisions, the type and number of sutures used, the physical manipulation of the tissues, and perhaps most important, minimizing tension on the healing incision. Rest assured that all of these things and a whole lot more are part of every plastic surgeon's training.
The issue of tension is one that deserves some additional discussion simply because it is so important, and it is something that you can help control. Whenever two edges of the skin are sewn together, the ideal situation is for them to come together easily without any stress or tension. But if there is a gap between the two edges the skin will need to be stretched to some degree to allow the two edges to join. This creates some tension on the skin, which tries to pull the incision apart while the healing process is trying to knit the two edges together. The result is usually a wider, more obvious scar.
Surgeons will do everything possible to minimize this tension by mobilizing the edges of the skin so they will come together easily. But after the operation, any swelling under the incision will tend to stretch the skin and contribute to tension on the suture line. That is where you can actually help yourself.
Following your operation the plastic surgeon will likely recommend that you wear either an elastic bandage or some type of tight-fitting garment for a period of time. He or she may also suggest that ice packs or cold compresses be applied to certain areas periodically for a few days after surgery. Both of these recommendations are made specifically to reduce swelling in the operative site. In doing so, you will not only reduce the amount of pain you experience but also help to prevent swelling and tension across the healing skin-and the result will be a better scar.
You'll recall that in the last chapter we talked some about various skin-care products and what they can and can't do. This subject invariably comes up whenever the discussion turns to surgical scars. "Isn't there something I can put on this scar to make it go away?" Again, scars never go away, but what they look like can be influenced to a degree by how you treat them. The use of pressure applied directly to healing skin by either a tight bandage or elastic garment has been demonstrated to help decrease the extent of scarring. In patients recovering from major burns, the use of custom-fitted masks, gloves, and sleeves for several months can dramatically improve the appearance and flexibility of even the most horrific scars. Extreme measures like that are typically neither necessary nor practical following most routine plastic surgery procedures. However, as I mentioned earlier, some surgeons will suggest that you wear a tight-fitting garment for a period of time to help reduce the amount of scarring you experience.
Various ointments containing vitamin E or silicone or other substances may help to keep the developing scar tissue soft and pliable. Many surgeons believe that it helps, so they often recommend that it be applied two or three times a day. Some even advocate that you buy vitamin E capsules and break them open to apply the concentrated liquid vitamin directly to the scar. No one really knows what vitamin E does to the skin or to the development of scar tissue. From a purely scientific standpoint there is no proof that this complex molecule, which is only partially absorbed by the skin, has any influence on healing whatsoever. Nevertheless, some people swear by it, and it probably doesn't do any harm unless you apply it too soon after your surgery. However, to be perfectly clear, you should never put anything on your incision sites without first getting the okay from your surgeon.
Liposuction
The same patients who ask about the tummy tuck "while you're in there" often suggest, "Why don't you just suck out some of that excess fat while you're there?" There isn't a surgeon alive who hasn't heard that at least once. Perhaps that message was what gave rise to the whole idea of liposuction, or maybe the patients got the idea because they had heard about the procedure. Either way, it is certainly possible to suck out some of the fatty tissue from under the skin using long metal tubes inserted through tiny skin incisions. This process is called liposuction, and it is not a weight-loss procedure!
Plastic surgeons sometimes use liposuction to supplement body contouring, but the process does not remove any of the excess skin. It can remove minor irregular bulges of fat in small areas, and is generally used as a "touch up" procedure after the major skin-removal operation has completely healed. Sometimes liposuction is combined with minor scar revisions as the "artist's finishing touches." Liposuction can cause significant bleeding under the skin with major bruising, which is usually only temporary. Even so, wearing a pressure dressing or elastic garment is generally a good idea following this kind of procedure.
Surgical Risks
Some plastic surgery procedures can be done under local anesthesia in the doctor's office, but that is not usually the case with body contouring. The extent of the incisions and the length of the procedures usually require general anesthesia. Likewise, because of the potential for bleeding during major procedures, some surgeons recommend having blood available for transfusion. This can even be your own blood that you donated a few weeks in advance. For these reasons, as well as others, most of these procedures are performed in a hospital or short-stay surgical facility, rather than the doctor's office. And, having the support services of a hospital can make it much easier to deal with any unforeseen problems.
After losing all that weight, patients tend to be healthier than they were going into the band surgery. The result is that nearly every surgical risk has been reduced. Underlying illnesses such as diabetes and high blood pressure may have improved, but it's important to realize that all of the potential surgical risks discussed earlier in the book still exist. They include possible problems with anesthesia, blood clots, heart problems, pneumonia, and so on.
Don't assume that just because you've had surgery before without a hitch you are bullet proof. Surgery is a bit like flying an airplane. It is an unnatural act that goes very smoothly most of the time. When something goes wrong it may be due to outside influences beyond anyone's control, but bad situations are far less likely if you follow a standardized "preflight check list." Be sure to discuss all the potential risks with your surgeon, and then do everything "by the book."
Avoiding infection is something that every surgeon strives for because infections can delay healing, increase scarring, and even risk the life of the patient. Fortunately, body contouring procedures are associated with a relatively low rate of infection, generally in the 1 to 2 percent range. Preoperative and postoperative antibiotics are routinely used, and along with careful skin preparation they help keep this risk to a minimum. Patients with diabetes or poor circulation are at higher risk for infection, as are those who have a history of staph infections.
The skin generally has great blood supply, and even when a large flap of skin is lifted away from the underlying tissues, it can survive based on the network of tiny blood vessels in the dermis. But in patients with diabetes, and particularly in patients who smoke, the blood supply of the skin may be severely compromised. The edges of the skin flaps may not get enough blood and oxygen to stay alive. If any part of the skin dies, it will need to be removed, creating a major defect. This will lead to increased scarring and may require more surgery, including possibly even skin grafts. If you stop smoking, even for just a few weeks, you can help reduce this risk, and breathing supplemental oxygen for a time after surgery may also be of some benefit. Some plastic surgeons will not perform procedures on smokers. It would be a good idea to stop smoking permanently anyway, so perhaps this will give you the incentive.
Recovery
Following a laparoscopic AGB operation, most people take only a week or so to recover. Plastic surgery is not laparoscopic surgery. The recovery is typically more prolonged, and depends in large part on what procedure is done. After a minor face or neck lift you may be fully functional within just a few days, but it can take six to eight weeks to bounce back from a circumferential body lift.
To a large extent your recovery time will also depend on what kind of work you do, how physically demanding it is, and your general health. Talk to your surgeon about this in advance so that you can make the necessary preparations. I have heard more than one patient complain after the fact about their struggles trying to go back to work after a body sculpting procedure when they hadn't allowed enough time to be fully ready.
It is important to get back into your exercise routine as soon as you are able. Don't use this as an excuse to take several months off; you may not ever get back into it, and you sure don't want to start gaining your weight back. Your surgeon should be able to give you a good idea of what sorts of exercises you can do and when you can begin.
Medical Necessity and Insurance
No discussion of plastic surgery would be complete without at least mentioning insurance. As a rule, most heath insurance companies are not going to cover elective recontouring of your body, no matter how much you argue with them. Your policy almost certainly has language in it that specifically excludes cosmetic surgery.
However, it may be possible to get some procedures covered by insurance if you can show they are medically necessary. This doesn't mean that you're going to get anywhere just because your doctor is willing to write a letter stating the importance of skin removal. It can be pretty hard to prove that chafing under your arms or between your thighs constitutes a medical condition requiring an operation that costs several thousand dollars.
The removal of the abdominal pannus or other areas of excess skin may be approved by some insurance carriers as necessary to treat a major fungal skin infection. But they are likely to require several opinions to that effect from doctors other than the surgeon who is treating you. A breast lift can also be considered as part of a breast reduction procedure, and these operations are sometimes covered by insurance. It usually requires you to show that the weight of the breast is causing neck, shoulder, or back pain. Again, this can be an uphill climb if you've just lost 75 or 100 pounds.
Certainly you should make every reasonable effort to get the benefits you are entitled to, and your plastic surgeon's staff will undoubtedly be able to help guide you through the process. They may even have some tips that you haven't thought of. If you're truthful and accurate in your arguments, who knows? All your insurance company can do is say no or maybe yes!
Conclusion
The most important message I can offer, and the reason this book was written, is to encourage you to do what you believe is right for you. Don't let someone else discourage you based on their bias. Don't fall victim to your own selfdefeated attitude that tries to convince you that you can't change your life for the better. Don't even let your doctor's reluctance to recommend weight-loss surgery dictate what medical conditions you must endure.
And finally, don't let an insurance company's denial stand in the way of achieving your success, whether it is getting plastic surgery near the end of your journey or getting an AGB to begin the process. Listen to your own heart, and find a way. It may be the greatest thing you will ever do for yourself.