Online Health Chat with Raymond Isakov, MD
Wednesday July 15, 2015
Losing excess weight is a major achievement. But once you’ve reached your goal, you might find that your body needs some additional fine-tuning. If the aftereffects of weight loss have left you uncomfortable or less confident with your body’s appearance, you might wonder if a cosmetic body contouring procedure is right for you. Body contouring refers to a number of different procedures that can improve body shape and contour, tighten excess or loose skin and enhance body image. Procedures include tummy tucks, liposuction and arm or thigh lifts.
About the Speaker
Raymond Isakov, MD is a plastic surgeon in Cleveland Clinic’s Dermatology & Plastic Surgery Institute. His specialty interests include body contouring; facial cosmetic surgery, including facelifts, eyebrow and neck lifts; cosmetic nose reshaping and non-surgical facial rejuvenation.
Let’s Chat About Plastic Surgery After Weight Loss
Moderator: Welcome to our chat about Plastic Surgery After Weight Loss: What are my Options with Cleveland Clinic plastic surgeon Raymond Isakov, MD.
Thank you, Dr. Isakov, for taking the time to be with us to share your expertise and answer our questions. Let’s get started with our questions.
script: I am considering liposuction or a tummy tuck. What is the difference and can these two be done together?
Raymond_Isakov,_MD: Liposuction is most effective when the patient has good quality skin. If there are stretch marks and poor quality skin, usually removing the skin is needed. Oftentimes, especially if one has had children, the muscle becomes stretched out and needs to be tightened. That cannot be accomplished by liposuction alone. Tummy tucks and liposuction can be done safely at the same time.
chrissie: Would removing excess skin from the abdomen help alleviate back pain in a 62-year-old woman post bariatric surgery? I also have had left-to-right incisions for a hysterectomy and have had two children.
Raymond_Isakov,_MD: Back pain is a very common problem, and it is often multifactorial. It is possible that removing excess skin, based on how much is there, would help a bit. That being said, in my experience and opinion, back pain alone is not the reason to remove the skin in most cases.
snail: What kind of results could I expect from arm lift surgery? How long do results last?
Raymond_Isakov,_MD: Arm lifts have high patient satisfaction if one is willing to accept a visible scar. Most patients who have lost a lot of weight do not mind the scars, and the results can be great. Any procedure we do will not stop aging, but you never get near where you were before the surgery.
jwinn: What is the best approach for a man to remove excess skin under his chin (turkey neck) or behind the ears? I have heard difference opinions.
Raymond_Isakov,_MD: The best way is usually with a facelift and neck lift. If the only thing that is bothersome is the "turkey neck," and a facelift is not in the cards for whatever reason, a direct excision can give dramatic results but at the expense of a more visible scar.
ModernKaveman: What is the percentage of people losing weight that have to get excess skin removed when they reach their weight loss goal?
Raymond_Isakov,_MD: To my knowledge, only about 20 percent of the patients get body contouring, but I do believe this is increasing. "Have to get" is a relative term. Most patients who lose a significant amount of weight will have extra skin to some degree. It is up to the individual person if they want or need skin excision.
mifrank: I had liposuction a few years ago and wasn’t very happy with the results. Is it okay to have a second procedure in the same area, and how long would I have to wait to do so?
Raymond_Isakov,_MD: There are never guarantees about results. Sometimes, even good patients get results that they are not happy with. Realistic expectations are always critical to success. Yes, you can have a revision procedure, but you would need to be seen to determine what needs to be done and if it is feasible. Surgery can be done at any time for you since it has been a long time since your first procedure.
chipmerz: How long after gastric bypass surgery do I have to wait before I can get a tummy tuck or arm lift surgery?
Raymond_Isakov,_MD: This is an important question. You basically want to be at your plateau for weight loss for a minimum of three months and have your health issues all sorted out.
edwinnah: Is achieving ideal body weight required before I can have a body contouring procedure?
Raymond_Isakov,_MD: You should be at your plateau weight for a minimum of three months. As for as the goal, this is different for everyone and is affected by where one starts off. This is variable. Going by BMI alone, I like to see patients under 30. That being said, this is not a hard cutoff and each patient needs to be assessed individually.
jeforsythe: How long after Roux-n-Y gastric bypass do you suggest getting plastics consult? One year? 18 months? Two years?
Raymond_Isakov,_MD: At least three months after you stop losing weight. This is often greater than 12 months but is variable.
janie: What should I look for in a plastic surgeon to make sure I will be getting the best treatment possible?
Raymond_Isakov,_MD: Start with plastic surgeons who are certified by the American Board of Plastic Surgery. Post-bariatric body contouring can be different, and a plastic surgeon often works with bariatric surgeons. You can also ask your bariatric surgeon, if you have one, who he/she would use.
lucia: What can I expect during a consultation appointment?
Raymond_Isakov,_MD: Communication is the most important thing. There are the history and physical exam, which are crucial. You and your doctor will also discuss goals and expectations, risks versus benefits, the surgery itself and recovery. Both the surgeon and patient need to be on the same wavelength.
jeforsythe: If we are attempting to have the procedures be covered by insurance, what would the medical name/code of the different procedures be (excess stomach skin, arms, etc.)? What are most commonly covered and/or what are their requirements?
Raymond_Isakov,_MD: This may be a tough one. The vast majority of the procedures are not covered. If the skin hangs below the pubic bone and rashes occur, insurance may pay for a panniculectomy. This is not a cosmetic procedure, though. The full abdominoplasty, or tummy tuck, is almost never covered, but inquiry on an individual basis does occur.
Shadylil: Does medical insurance pay for excess skin removal?
Raymond_Isakov,_MD: Each insurance company has its own criteria, and you have to get preauthorization for that. Some will pay for the excess skin removal. If the skin hangs below the pubic bone and rashes occur, insurance may pay for a panniculectomy. This is not a cosmetic procedure, though. The full abdominoplasty, or tummy tuck, is almost never covered, but inquiry on an individual basis does occur.
hooperd: Who should you call if you had bariatric surgery but no longer can see that doctor because he is out of network?
Raymond_Isakov,_MD: You should continue to be followed by physicians in the bariatric institute or where you had the procedure performed.
contrast: What risks are associated with body contouring procedures?
Raymond_Isakov,_MD: These may not be small procedures. The risk is based on what is done and also on how many procedures are done at one time. Bleeding, infection and open wounds can occur as with any surgery. These risks are most often minor. Larger problems can also occur. Medically, you will need to be assessed well beforehand. Prevention of blood clots in the legs is important so we use blood thinners, when indicated, and have the patients ambulate quickly. Safety is very important.
jwinn: Is it best to break the surgeries into multiple procedures. For example, tummy, under arm, breast (man) followed by rear, back and thigh in a second procedure as opposed to a 360 procedure around the waist? What would one expect to pay for the two difference approaches? My insurance will cover the front tummy but not the others. What would the approximate out-of pocket be for the other aspects?
Raymond_Isakov,_MD: I do break it into stages, but in the right patient would do multiple procedures. Going "360" is common in one stage. Other procedures need to be evaluated individually. Cost is variable.
easeypeezy: How much body contouring can be done at one time?
Raymond_Isakov,_MD: A good question. The answer can be complex, as every patient, surgeon and hospital is different. It is not uncommon to do a few areas at the same time, but it is never wrong to stage the procedures. I look at each patient individually and try to limit time on the OR table. Safety is paramount.
jwinn: Are the procedures done in a clinic or in the actual hospital?
Raymond_Isakov,_MD: We use either our hospital ambulatory surgery center or the hospital OR itself. This is based on medical condition, the amount of surgery to be done or sometimes just scheduling. Outpatient surgery centers that are accredited should be fine based on the amount of surgery and the patient's health as well. These are not the kind of procedures I would do in an office.
jwinn: What is a reasonable expectation regarding scaring? Many of the before and after photos show some pretty large and red, and even uneven, scars some seven to nine months after surgery?
Raymond_Isakov,_MD: Oftentimes, the pictures you see are taken fairly early. The scars do usually fade with time, more than 12 months, but are always there, usually, a good trade-off, however. If you are not willing to have scars, then the operations are not for you. There is no way to do it without scars.
jwinn: Can Cleveland Clinic provide a second opinion using the medical photos from another surgeon?
Raymond_Isakov,_MD: Photos do not replace examining the skin but give a good general idea. We have a service called MyConsult, which is very helpful for this.
jwinn: Can Cleveland Clinic accommodate an out-of-state patient? If so, what does it take to do that successfully? Are the any special accommodations for those patients? How are follow-ups handled, for example?
Raymond_Isakov,_MD: You may request assistance from our Cleveland Clinic Medical Concierge.
Moderator: That is all the time we have for questions today. Thank you, Dr. Isakov, for taking time to educate us about plastic surgery options following significant weight loss.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.
To make an appointment with Dr. Isakov or another Cleveland Clinic cosmetic surgery specialist, please call 216.444.6900 or toll-free at 855.383.7843. Visit us online at clevelandclinic.org/renewyou.
For More Information
Cleveland Clinic’s Department of Plastic Surgery Cosmetic & Plastic Surgery Center provides expertise for both surgical and non-surgical cosmetic procedures ranging from body contouring and breast surgery to chemical peels and facial injections. The Center offers patients access to a range of cosmetic specialists including plastic surgeons, dermatologists, head and neck surgeons and aestheticians.
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