Making the Best Body Contouring Decisions for You

Dr. Basu (00:12):
Welcome back to Behind the Double Doors. I'm Dr. Bob Basu. On today's podcast, we're going to answer all your questions about surgery for loose skin following weight loss. Obviously, tons of health benefits from weight loss, whether it be through your cardiovascular system, your skeletal system, your joints, your organs, your kidneys. The list of benefits from weight loss goes on and on. I think since we're talking about loose skin, there's also a lot of changes going on to the quality of your skin. Not only do you lose volume, meaning from fat loss, but this can also manifest with loose skin and the type and quality of your skin can significantly change. It's quite common for us to see this. So what happens to the skin with weight loss, whether it be 10 pounds or 210 pounds, you can lose that elasticity to the skin. What that means is that you're losing the tone, the tightness of the skin.

(01:07):
Some people see this with stretch marks. Some see this with severe laxity. They lose that recoil, the tightness of that tissue. So in addition to just removing skin, board certified plastic surgeons who are experienced with body contouring after weight loss or facial contouring after weight loss, they have to also consider the quality of your skin has changed, and that's a really important part of a treatment plan to manage loose skin after any weight loss. If you're nutritionally optimized and you're physically fit and active and you're maintaining your muscle mass while you're losing weight, I do think the elasticity is a little bit better. But a lot of this has to do with genetic factors, and you can do everything you need to do nutrition working out, which is great, but if you have the genetic factors that are going to lead to poor elasticity, meaning poor tissue quality, then there's really not much you can do.

(02:00):
I would say in my practice, two thirds or more of my patients have lost weight in some form, whether it be from a history of bariatric surgery, whether it be through diet and lifestyle changes, or whether it be through some of our GLP one weight loss medications that are out there, or any combination of those things, right? I would say at least two thirds of our patients are coming in with a weight loss history. Weight loss contouring is its own unique subspecialty in plastic surgery. So I would always give advice to anyone looking for body contouring or facial contouring after weight loss, seek care only for my board certified plastic surgery, who has extensive experience helping the weight loss patient. Every week I see patients who've lost weight, who come in wanting everything transformed head to toe. They want to face a neck lift, they want to address their breasts, they want to address their tummy, back, arms, legs.

(02:53):
And what I ask the patients, and I look, we live in an insta world, right? We want everything done right away. We want no recovery, and that's just not reality. So what I always ask my post weight loss body contouring patients is what is your number one area of concern? What is your number two area of concern? And then what is your number three and four? So I basically have patients triage their priorities, essentially what's your one, two area of concerns? I don't ask them to tell me which procedures they want. I simply want them to focus on the areas that bother them. And then together we come up with a comprehensive plan that we can maximally treat the number of areas safely. Couple things that I look at, patient's health status, their age, their fitness level, other medical issues that I evaluate to determine how much surgery that we can do safely in one setting.

(03:43):
And I always tell patients, don't feel pressured you need to do everything at once. Sometimes it's better and safer to do less and less is more. Sometimes it's better to do a smaller procedure and come back and fight another day. So I know a lot of people want to get everything one and done, I get it. But sometimes it's better to do less, and that's often more. Every weight loss patient is different. I have patients that come in and what really bothers them is their face and neck and which case we're going to be talking about a deep, plane face and neck lift. I have other patients that come in. Their concerns are the arms, the loose skin hanging from the upper arm. Others have concerns regarding their breasts, whether it be volume loss and or sagging. Other patients' priorities are their tummy, their waist.

(04:28):
Sometimes it's the backside. They have a lot of rolls on their, sometimes it's volume loss in the buttock and sometimes it's all of it, right? And so there's no right or wrong way. Again, it goes back to the patient's priorities. Now, if they want me to create a plan from the collarbone down to the buttock area, one way, again, this is not right for everybody, but one way is to divide up the body into two zones. And when I say the body, we're talking about from the shoulders down to just below the buttocks, and one way to divide up the body is basically drawing a imaginary horizontal line from your rib cage across. So we're kind of dividing the upper trunk, and the upper trunk means your arms, your sides, and your breasts, and it might also include your back. The lower trunk, meaning everything below that horizontal line, that's the lower body.

(05:15):
And where oftentimes we can do what's called a circumferential body lift, which is basically a 360 tummy tuck, that's another term for it, or a belt lipectomy. But a circumferential body lift includes multiple procedures in one. Number one, it includes the tummy tuck in the front of your tummy. It also includes an anterior and lateral thigh lift with a waist reduction. As we continue the incision to the backside, that includes a lower back lift and a buttock lift. And very common for patients who've lost weight because they're concerned about volume loss, they've lost all the volume in their buttock. We can often do some other procedures to help enhance the buttock, whether it be through fat transfer or some advanced techniques called auto augmentation techniques, or a combination of those two. So one approach to this is to divide up the body into two zones.

(06:05):
One of the universal principles for body contouring after weight loss, quite frankly, it's a universal principle for everything that we do in plastic surgery, is that we have to accept some degree of scar to achieve that much, much better form. Now we get it, we don't want our patients to be riddled with bad scars, so we try to hide those thin little incisions in natural body crease line. So for instance, in a tummy tuck, we are strategic about where we place the scar. The thin incision line is typically placed in the undergarment bikini line below a C-section scar if a patient has a C-section. So that's an example of how we hide the scars. But there's some procedures that it's really hard to hide the scars such as an upper arm lift and an upper arm lift. The traditional technique is placing the incision in the medial aspect of the upper arm.

(06:57):
I'm not a big fan of that technique. For two decades, I've done an upper arm, therefore I hide the incision in the underside of the upper arm, because I think it's a lot more forgiving. And a common question that we get is how will my scars look? And I always tell patients that scarring has to do with two variables. Number one, it clearly has to do with surgical technique. So what I do or what your surgeon does, how they handle the tissue, how they close the tissue, are they doing a real meticulous cosmetic closure clearly matters, but it also has to do with the second variable, which is patient genetics. Now, I'd love to tell you that I'm so awesome that I'm going to trump a patient's genetics that is simply not true. Now, look, we get it right, over two decades, I work with patients that have great healing potential, and I do a tummy tuck, and I can't even see the scar week 4, 5, 6 after surgery.

(07:52):
But I also treat patients that don't have great healing potential or don't have great genetics, and their scar takes the classic 18 months to fade. Now, we get that variance at how patients heal, and that's why after every surgery, it's not that you have the surgery and disappear. Typically four to six weeks after your surgery. We have a pretty involved scar management protocol that includes scar massage therapy, that includes microneedling, laser lightening. There's a lot of things in our bag of tricks in our toolbox that we can really work at making those scars fade away as fast as possible. One of the most important factors is making sure you're working with your team, your plastic surgery team, that you've given yourself enough time for recovery. The worst thing that you can do is you undergo any procedure, small or big, and I'm sure your surgeon's practice is going to go over what you should be doing, what you should not be doing, and how to prepare for the recovery.

(08:45):
But if you kind of ignore that and do whatever you want, you are setting up for a complication. So what I love to tell all my patients is what I do in surgery is equally important as what the patient does after surgery, equally important. It is vital that the patient and the surgeon are working together as a team and being really honest about the limitations, what they can do. So if they can only take two weeks off and they have to be at a desk job, then maybe it's time to do less surgery. Or if they have little kids and they have no childcare support, maybe that's not the right time to do a surgery. So proper planning is so, so important to set you up for a successful outcome. One of the increased risks that weight loss patients carry is an increased risk of a fluid collection.

(09:31):
The medical term for that is a seroma. What that means is that when we are removing tissue, we're doing work underneath that tissue and doing our thing, we close things down, there's an empty space where we've worked, and that empty space needs to heal down. Now, there's some advanced techniques that we do to expedite your recovery, such as drainless techniques. We do a special negative pressure therapy or drainless closure system called Interi. But even with all the advanced techniques that we do, once that space is healed down, if a patient is not giving adequate time to heal and they start moving around doing too much activity, they go back to the gym too soon, they're walking around too much. That can unheal those areas internally and lead to what's called a seroma or fluid collection. Now, that's not life-threatening, but it can potentially negatively impact your cosmetic results with swelling, scarring, and an undesirable impact to your overall outcome.

(10:26):
So it's really important to make a commitment and work with your team to follow postoperative instructions so you can enjoy your results and get back to life as soon as possible. So when's the right time? Sometimes patients say, well, I want to lose five or 10 more pounds. Great goal to have. But the reality is what I look at is are the patients, for instance, those patients that are on the GLP one medications, if their weight loss has slowed down and they've been stable for a while, then I think that's really a good time to consider a surgical procedure. Patients don't realize that when we're going to do a tummy tuck or we're do an arm lift, we are going to be removing a few pounds. I mean, there are body lifts that I've removed 20 pounds of excess skin and fat. There are body lifts that have removed five pounds, but typically on a circumferential body lift, I'm removing about four to 10 pounds of tissue circumferentially.

(11:19):
So when patients say, well, I want to lose five or 10 more pounds, so the circumferential body lift, although it's not a weight loss procedure, removing that loose skin and fat will remove those pounds. So I tell patients, as long as your weight loss is stabilized, you're in a healthy place, then we can consider a potential procedure for you. But every patient is different in their weight loss journey. So it's hard to give a kind of an umbrella statement that'll apply to everybody that's out there. Every surgeon has their unique criteria. Since my practice has been at least 50% focused on helping patients who have lost weight, I do help patients who have a higher BMI. The typical cutoff for most surgeons in the United States is they want the BMI below 30 or 31. Nothing wrong with that. The reason is there's plenty of evidence in our literature, meaning in our journals that show when the body mass is higher, higher than 30 or 31, the risk of complications go up.

(12:13):
What are those complications? They're all of them, right? But primarily it's seromas, fluid collections, wounds, and the list goes on and on. Now, I've helped patients who have lost a hundred pounds, 150 pounds, 200 pounds, whether it be through bariatric surgery or through the GLP one weight loss medications, and prior to their weight loss, their body mass index, which is a ratio of height and weight, used to be 55 or maybe 60, but even after losing 150 pounds, their body mass index is still 38, and they're struggling to get it down. So I evaluate the individual patient. We do help patients with a higher body mass index. I have an extensive experience. We're actually writing up our experience because I think there's a paradigm shift of what the threshold should be based on our experience and some of the state-of-the-art techniques that we do for higher BMI patients.

(13:06):
But I find that patients who've lost weight do tend to do very, very well. We have some things that we do uniquely that help minimize those increased risk, like increased risk of seromas. But patients do need to understand that if they have a higher body mass index, even with my experience level, even with all the new modalities and technologies we do to try to minimize risk higher BMI procedures are still higher risk. Period. The typical recommendation from the anesthesia societies and our board certified MDI anesthesiologist, who's been on staff for this full-time for many, many, many years, is that you really should be off of these medications for at least 10 to 14 days. And the reason why anesthesiologists want you to be off these medications for one to two weeks is that remember, some of these medications slow down your gastric output, meaning how things flow down, it slows things down, right?

(13:56):
Well, if things slow down, you could still have some stuff that you ate before sitting around your tummy, right? Well, you don't want that stuff backing up while you're asleep because that can increase the risk for what's called aspiration. That's the medical term for where food contents back up and go into your airway. And that could lead to what's called aspiration pneumonia, a lung infection, right? Completely avoidable. To play it safe, it's good to be off of these medications for about 10 to 14 days. Ask your board certified plastic surgeon what their recommendations are. Their anesthesiologist may have different guidelines, but typically it's about one to two weeks you got to be off of that. How long should you stay off of GLP medications after surgery also varies based on who your surgeon is and what kind of surgery you're having. Typically, I like the patients to be healed before they restart.

(14:47):
Why? While you're healing, your body's hungry for nutrition, right? You need a lot of protein. You need the building blocks so your incisions heal well, your scars are fading well. And so when your body's hungry for nutrition, you don't want to take any medications that are limiting your caloric intake, right? So that's where we really focus on supercharging your protein intake, not just before surgery, but after surgery. Supercharging your multivitamins. Nutrition is such an important part of healing, and it shocks me, it's still underused. In surgical care. We want to nutritionally optimize our patients, all of our patients, whether you've lost weight or not, because those patients who are nutritionally optimized, they heal faster, their swelling is less, they have less pain, their scars fade faster, everything's better. But for patients that are nutritionally maybe not optimized or have suboptimal nutrition, you're asking for problems, right?

(15:44):
That's where you're having challenging or slower healing process. Maybe you'll see suture spits, meaning where sutures start eroding through the skin, increased risk for seromas, which is a fluid collection. So we really talk to all of our patients about having not just a surgical plan, but a good nutritional plan so that they heal well after any plastic surgery procedure after weight loss with loose skin. I also want to set patients' expectations correctly. Even in my hands with all the experience when I'm doing circumferential body lift, I have patients who've lost 150 pounds, and some patients I can get them looking like they have a contoured six pack abdomen where they look like a fitness model influencer. With other patients, same amount of weight, different tissue quality. I'll do the same procedure, same techniques. I'll do some soft ab etching, but they will get some relaxation of that skin.

(16:38):
What does that mean? It means they get some looseness. Now, it's not going back to what they had before, not even close, especially when you're removing 5, 10, 20 pounds of loose skin on a body lift. However, they can potentially get some relaxation of the skin. Why? Because remember, we talked about the tissue quality. All of us are working with the tissue that you have. We cannot change the intrinsic quality of the tissue. Now, there's some technologies that we have such as radio frequencies that could help build collagen, but ultimately there's some inherent limitations. So why does some of my weight loss patients get incredibly fitness model results? And I'm doing the same procedure on other patients. They're getting a huge improvement, but it's not as toned because it has to do with the variability of your tissue quality. Again, when I meet with a patient, I can talk to you and give you some insights.

(17:31):
Even in the worst case scenario where you have really bad tissue, plastic surgery procedures following weight loss still give incredible transformations. It's just the degree of tightness and the expectations. And one of the things I really try to do is to set expectations appropriately cuz there are limitations sometimes of we can achieve. I guess another way to think about this is why are some moms who have three kids, their skin coils back where their BFF has three kids and their skin drops to their thighs? A lot of variables there. Ultimately, it's the genes you got. I think it's genetics. For patients that have really weak tissue with a breast lift, I can also add in the internal bra technique. Now, many of the listeners have heard me talk about the internal bra technique. I'm very passionate about it. So what is it? So the internal bra technique in a breast lift, let's go back to why we're even talking about it.

(18:24):
So when we do any breast procedure, whether we're talking about an augmentation, an augmentation with a lift or a lift by itself, whenever we do these procedures, what holds these procedures up to where you want the breast to be? And the answer to that question, it's your tissue quality, right? It's your tissue quality. It's always your tissue quality. So what do we do for patients that want their breasts to sit a lot higher on their chest wall, but they're either born with weak tissue, they have a weight loss history, maybe the weight loss came from the post pregnancy changes, or they're just born with weak tissue. We have to do something else besides depending on their tissue to help give them the result that they want. And that's something else is the internal bra protecting where I'm using something else besides your tissue, that something else is a resorbable mesh.

(19:11):
Now, when I say the word mesh, I always clarify. This is not that mesh that you see late night TV commercials that are creating problems, right? This is made out of suture material that's been around for a long, long time, decades. But the company that made this resorbable or dissolvable mesh was very, very clever. They took the sutures to been around for decades and they weaved it into what looks like a mesh. And we can place that mesh strategically to give a little bit more support. Now that mesh sticks around for two to three years, and as it dissolves, your type three collagen replaces it naturally giving long-term support. So that's one way that we can give you a little bit more support. If you're confused by everything that I just said. What the internal bra technique does is recreate the effect of your favorite supportive or pushup bra without having to need that bra.

(20:01):
It's internalizing. Weight loss impacts different patients in different ways in different places, and everyone's concerns are very, very different. So it really requires a very specific discussion, helping the patient prioritize their goals and the expertise to come up with a unique plan. And let me dive a little bit deeper on the expertise. This goes beyond board certification, right? So that's the minimum, right? You have to see someone who's certified by the American Board of Plastic Surgery. You have to see someone who's a member of the American Society of Plastic Surgeons. Accept no imitations, no matter how fancy the name sounds, period. Hard stop. Now, beyond that, I'll give you an example. I see a lot of women who are very, very petite after their weight loss. And their concern is they want a body lift, or they're concerned that their buttock is hollow. They've lost their buttock.

(20:53):
They feel insecure wearing yoga pants when they're exercising. And they've been told by reputable board certified plastic surgeon that you're just going to have to live with it. I can tighten your skin in the back of the buttock lift, but you don't have any extra fat. You have to live with it. Not the case. I have done what's called composite gluteal augmentation on patients who are extremely thin. They're not candidates for fat transfer by itself because they don't have enough extra fat left after their weight loss. So what I've done is use the love handle tissue in a buttock lift. In fact, my patients have called this procedure love handle buttock augmentation. So when I do a buttock lift, the extra skin that's in the flank areas normally thrown away, right? We're pulling the buttock up. I take that love handle tissue, keep it attached to the blood supply, and create the patient's own natural tissue implant.

(21:46):
And we can actually place that in the buttock. And if I can find a little bit of fat anywhere, whether it be in the medial thighs, I take a small amount, kind of think slim BBL, and add in some fat grafting around that flap, that love handle flap to give them what's called a composite gluteal augmentation. I've done this on patients who are repeatedly told by reputable surgeons that they're not a candidate. They have to live with a flat butt. We have some incredible before after pictures on these very challenging patients. So the expertise matters, right? And I've learned this technique over two decades and honed it and do it even in these very thin slim patients after weight loss. And they're incredibly happy with the results. And we're going to be sharing one recent result on our Instagram page very, very soon. Fast forward to today, there are some non-surgical ways to volumize your butt today, very powerful.

(22:39):
There's a new product that is a bio-engineered fat. Think of fat out of a syringe. So everyone's heard of fillers. This is not a filler. The company did a lot of research and they take fat from a cadaveric source and irradiate it, they zap the fat with radiation that kills any bacteria infection. They wipe out all the immune components. They add in what's called extracellular matrix and these proteins that support the fat to give it structure. And you can actually have a buttock augmentation now using this bio-engineered fat. This can be done in the office. It's not a surgical procedure. There's no downtime. You can go to work the next day. What's the downside? Long-term results, I've been doing a few months, but we don't have one to two year follow-up. In theory, the fat graft survival rate should be about 60 to 80%, but we shall see.

(23:37):
The other downside is this is a new product. It is incredibly expensive. It's very expensive. So if a budget is of concern, this potentially could be price prohibitive. When you come in for the consultation, you're going to actually meet the patient consultant that you've been speaking with and dialoging with, and again, revisit a lot of the information so that you're well-informed about potential options and alternatives about costs, recovery, and so forth. And then of course, I come in and meet with you and also review what your priorities and goals are and what your dreams are, and what are you aspiring to look and feel like. And then we then jump into a physical exam. After I reviewed your medical history, making sure you're medically optimized, or if we need to do additional workups and the physical exam together, we identify the areas of concern. I evaluate your tissue quality and illustrate to you where incisions will be placed in different treatment options.

(24:32):
Go over the recovery, discuss the potential risks, and what we're going to do to minimize those risks and what we do with advanced pain control techniques so that you're very comfortable after the procedure. And so our goal is really after the consultation, you are really well-informed about what your options are, and you feel fully empowered to make the best decisions for yourself. The best starting point is to listen to our podcast. We've interviewed several patients who have generously shared their personal journey with their weight loss and their post weight loss plastic surgery procedures. That's a great starting point. You can also contact our office at 7 1 3 7 9 9 2 2 7 8 and speak to one of our patient consultants who can introduce you to some patients who have offered to educate others. Surgery is a big decision, and getting all the information you need is very important. And I think talking to somebody who has gone through that is very helpful so that you get a really good understanding of what to expect moving forward.

Announcer (25:33):
Basu Plastic Surgery is located in Northwest Houston, in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That's BASU Plastic Surgery. Behind the Double Doors is a production of The Axis, theaxis.io.