Total Body Surgical Blog

As surgeons that wear many different hats during the week (Cosmetic Surgery, Reconstructive Surgery, Bariatric Surgery, and General Surgery), Dr. Swetnam and I are faced with constant challenges; and it is a significant challenge to keep everyone satisfied.  As one of my favorite subjects, today I'll discuss post weight loss cosmetic surgery.

Typically, bariatric surgery patients first and foremost have decided to take the plunge in changing their lives.   I heard it best this week from a patient who told me, "Dr. Miller, I am sick and tired of being sick and tired." It's a lifetime of habits that they must break: the way they eat, the way they exercise, even just the way they think. The positive repercussions of weight loss are legion.  It truly is an entire lifestyle change.  It is amazing for me to see how one positive change by a bariatric patient effects those around them.  I recently saw a patient that was 12 weeks out from a sleeve gastrectomy.

To both of our satisfaction, he had already lost 70 pounds.  On top of that, his wife had also lost 30 pounds just by following the same diet that I'd ask him to impart postoperatively.  The little cherry on top of all this icing post surgery was that their daughter had also decided to begin to make healthy food choices, resulting in weight loss as well.  It's amazing how one positive decision begets another positive decision.  Unfortunately, one of the few anticipated post weight loss "problems" (besides having to purchase a new "skinny" wardrobe), is what to do with all the extra skin that sometimes results from losing excess weight...? The thing is, not everyone ends up with excess skin.  Really, it depends on multiple factors: the patient's age (no, I didn't just call you old); how many children a patient may have had; excess roller coaster weight loss and gain over the year; and the personal skin elasticity of a patient.  The latter really making the majority of the difference.  Quite honestly, it really comes down to how you picked your parents when it comes to skin elasticity.  Genetics is key to just about everything under the sun, and skin elasticity certainly falls into that category.  So why does this matter? Think of it this way: if you have a 10 pound sack of potatoes and take out 9 pounds of those potatoes, you've got a lot of sack left over, right?  Sometimes this sack shrinks down, and other times it does not.  Again, all as a result (or lack thereof) of the degree of skin elasticity someone may or may not have.   I am often asked if exercise will help to tighten up the skin. Unfortunately, I can assure you that all the situps and jogging in the world will not help that excess skin to shrink.  So, what is the answer then?  What do I do now that I've lost this weight and my skin gets rashes between the folds?  And sure, I've lost a significant amount of weight, but my clothes still don't fit right lugging this extra skin around!  This is where the post weight loss recontouring comes into play. 

     Though not every post weight loss patient needs them, there are multiple  body contouring options for those that do post weight loss: tummy tucks, liposuction, arm lifts, breast lifts, thigh lifts, and body lifts. Typically, one or a combination of these procedures have been successfully used after weight loss surgery to refine patients’ bodies, and help them enjoy everyday activities as they envisioned at the beginning of their journey.  The most common procedure that Dr. swetnam and I do is the tummy tuck.  Essentially, that entails not just removing the excess skin present, but also tightening up the actual abdominal muscles.  We basically create an internal corset that results in a waist that many people had not seen for many, many years.  Following the tummy tuck, I would say that breast lifts are our next most common procedure post weight loss.  It's amazing to see how people's attitudes change as they continue along their weight loss journey.  Specifically, people who had become shy wall flowers virtually become alive again. Their inner personality that had been stifled for so long is reawakened.  No longer just satisfied to wear bulky sweaters and oversized tshirts to hide their insecurities, they sometimes pursue breast lifts.  Breasts that were once being tucked into their front pockets are now perky and full on the top of their chest- right where they should be.  Following breast lifts, arm lifts (sometimes termed brachioplasty in doctor-ese) would be the next most common procedure that Dr. swetnam and I perform.  It is essentially just removing extra skin and remaining fat to create a nicely contoured arm again.  Thigh lifts are much like arm lifts, except just a bit further south.  I would say that thighs are the most challenging to operate on, as God didn't create us in anticipation of having incisions in our groins (location required to lift up those thighs again).  I should mention here that the great thing about having two fellowship trained cosmetic surgeons together in a group means that more procedures can be done at the same time.  Why does that make any difference? First and foremeost, the operative time is more than halved.  This is not just better for the patient's health, but also is more cost friendly for the patient in the long run. 

     So when should a post weight loss patient consider having body contouring procedures done?  Typically, I suggest that a patient be within 80% of their weight loss goal.  Typically, this is at sometime between 12 and 18 months.  As I said, body contouring is not something that is essential from a health perspective, but rather as the end result of a long journey.  It's basically seeing the final end point result come to fruition.  It has been said more than once that we are flattered to be a part of this whole process, both as the wearing the weight loss surgeon's hat, as well as that of  the body recontouring surgeon's.  We literally know our patients inside and out!   

Come see us today for your complimentary Cosmetic consultation!!  918-786-7780 or 1-877-weight-0. 

Let's have some fun today.  It's been a little while since we had a little audience participation and I think it is time to change that.  Sooo, it's test time again!! 

Here are the rules:

1.  Look at the picture and see what you think would help.  (those of you who come here often will find it easy...you are educated!!).

2.  The choices will be between using Botox, a Filler of some sort, laser, or a surgical procedure.

You may elect to combine the use of these tools and that is OK.  I do it all the time.  Today though, let's not get too complicated.  In my analysis of the patient I will give you some ideas on what other things would be good for the patient.  I need to feel useful in some way!!

Always remember, there is no right answer, because, in Cosmetic surgery everything is elective.  You can always choose to do nothing.  However, there are wrong answers.  Wrong answers are when you plan to do more than the patient needs or wants.  My job is to steer people away from unecessary procedures and only do what's needed or desired...today, that's your job.  Good luck!!

Example #1: 

Here we have a 40'ish female with no other medical problems.  She complains that she looks "old" and wants a face lift or something to help her look the way she feels.  Look at her closely.  What do you think??

What would you recommend:

1.  Botox  2.  some type of filler  3.  laser  4.  a surgical procedure

Example #2:

40'ish young lady who complains about the lower part of her face sagging.  Her friends have told her that you have helped them and she should come talk to you about what could be done.  You would recommend???

  Your recommendation??

1.  Botox  2.  a filler of some type  3.  laser  4.  a surgical procedure

Example #3:

A 54 year old lady who is disgusted with her neck and just thinks she looks OLD!!  She says that cost is no obstacle and wants it all fixed, or injected, or something! 

 And the winner is....

1.  Botox  2.  some type of filler 3.  laser  4.  a surgical procedure

Example #4:

28 year old female who states her boyfriend says she has "wrinkles around her mouth".  She is concearned about this and wants to know what you think....

  Here she is...

1.  Botox  2.  Some type of filler  3.  laser  4.  surgical procedure  5.  get a new boyfriend!

Example 5:

A 65 year old widow comes to you and says she has finished mourning the loss of her husband and wants to look younger so she can "get out there".

  Very nice lady....funny too....what would you recommend??

1.  Botox  2.  some type of filler  3. laser  4. Surgical procedure  5.  Birth control

Well, let's see how you did.  On number one if you said Botox, that would be a great start.  Most people want to start small.  Botox would get rid of the lines around the eyes and in the upper face.  She will eventually probably want a brow lift to eliminate the lines and the cause of them but Botox is fairly cheap and less invasive.

On number two, I would say Botox and some type of filler.  This combination is great for softening wrinkles in the upper face and getting rid of nasolabial folds as this lady has.  She has good facial structure and her skin is in good shape.  This will make her very happy and not cost a fortune.

On number three, I would recommend a surgical procedure or two.  Looking at the "hooding" over her eyes, she would benefit greatly from a brow lift.  It will take years off of her appearance.  She also has the "turkey gobbler" neck and jowling but her neck is not heavy.  I would recommend a mini lower face and neck lift as well.  She will be very happy!

On number four....get a new boyfriend of course.  We see people like this sometimes and my job is to DO NOTHING.  She needs to be told how beautiful she is and just how silly it would be to do anything to change that.  Unfortunately, in many cases, these people will find someone to mess things up.  It's sad.

Number five would need a brow lift, upper eyelids, face lift, and I would also recommend full face laser to treat the discolorations and fine lines on the rest of the face.

I hope you did well on the quiz today, and enjoyed using your own evaluation skills.  If you like, let me know how you scored and if you have anything you would like addressed, send that too.

Call us at 918-786-7780 or 1-877-weight-0 to make an appointment.

Possibly more changes on the horizon for weight loss surgery are in the making.   

These changes will have an effect on the entire landscape of bariatric surgery in the U.S.  First, a little history....

When bariatric surgery first started (weight loss surgery) there were few regulations and a multitude of procedures that were tried.  All procedures were done through a large incision and most of the patients are high risk due to their weight and many other additional medical problems brought on by the weight, i.e., diabetes, high blood pressure, heart disease, sleep apnea, etc.  This combination led to a high complication rate and high mortality.  What has changed in the past several decades to make these procedures much safer is the innovation of laparoscopy.  This allows us to do the procedure with tiny incisions, fewer wound problems, much less pain, and shorter hospital stays.  Other changes that have happened are the standards that were set for bariatric centers. These standards were fairly rigid and the procedures done were made more standard.  What we have learned is the bariatric patient needs a higher level of pre-operative evaluation and post-operative care than the average patient.  Because of this, the American Society for Bariatric Surgery was formed and guidelines were created to improve safety and "centers of excellence" were created.  Centers of excellence were formed based on criteria set for pre and post op care, and a minimum number of cases done in a year. 

After gaining experience and analyzing a ton of data, it was discovered that the center of excellence really does not change outcomes.  What this means is you can have a procedure done at a center of excellence or a non-accredited center and have just as good an outcome.  The net effect of the center of excellence has been to limit access for medicare and medicaid patients with no real benefit.

After joining forces, the American College of Surgeons and the American Society for Bariatric Surgery are trying to change (in my opinion for the better) the center of excellence guidelines.  Here is what the proposed changes will look like:

1. Three divisions will be set up, the first being band centers, where only lap bands will be performed.

The Gastric Band on the stomach.

The second division will be "low acuity" centers of excellence.  These are smaller facilities "like INTEGRIS Grove hospital" that have qualified surgeons but limited ancillary services.  These centers will be able to do staple procedures on "lighter" individuals with few other medical problems. In other words, healthier, lighter patients will be able to have their procedure done on a more local basis and not have to travel to big centers.

Sleeve gastrectomy                                               Gastric bypass

In these lower acuity centers, the work up is the same and all of the patients are tracked by a National Data base.

The third division is the high acuity center.  This is where heavier and more complicated patients will have to go, usually in the larger regional hospitals.

This is the proposal that was sent to the CMS (Medicare).  However, they have different ideas about the whole thing.  CMS, looking at the data, thinks that possibly communities would be better served if the whole center of excellence thing was just eliminated.  They do have a substantial amount of data that shows there is no improvement in outcomes.  Now the Politics come in.  What politics?  Well, current centers of excellence don't want any change and centers that want to gain this distinction can't because the number of cases that must be performed, under the current rules, cannot be reached.  The number of people needing the surgery continues to grow and many cannot get to a current center of excellence for care.  My feeling is that if you have a qualified surgeon and a program in place....what difference does it make.  People that need the surgery should not have to travel hundreds of miles, and according to the data, it makes no difference.  Hopefully, a reasonable compromise will prevail....and soon.  Many programs, ours included, are sitting on go, waiting for some sort of direction.  In the mean time, we are limited to private pay patients and private insurance patients currently.  We are looking for some type of decision in 2014 and are hoping for good things.

   Of course the changes will mostly only effect Medicare and Medicaid patients but some private insurance as well.

So that is what's on the horizon...better access.  We hope to be a low acuity center in the very near future as Dr Miller is fellowship trained, certainly qualified, and ready to go!

Our cash prices are pretty good too (see below) and you don't need to travel to Mexico either!!

So come see us today!!  Cosmetic consultations are always complimentary!! The spring laser liposuction special is going on so act now to reserve your time!  918-786-7780 or 1-866-weight0.  And don't forget our low prices on breast augmentation either!!!

Keep an eye out for the news reports on the sleeve gastrectomy!!!

Winter time is vein time a wise man once said (that's me ya'll)!!

Why is winter time the time to worry about those pesky leg veins??  Well, it's because you are already wearing pants.  In spring and summer we want to wear shorts, or other more revealing clothing, it is then too late to conseal any ongoing treatment.  In winter, the healing process can take place under your clothing and people won't ask too many questions.  Now is the time to treat spider veins and larger varicose veins.

Spider veins are small areas that most of us get as we age.  These are pesky and ugly but usually do not indicate any major underlying problem with the larger venous system, although they can be an indicator.  They look like the skinny legs of a spider, thus the name.  They can also look like a bruised area that doesn't go away.  Spider veins progress with time and can be made worse by certain occupations..standing, etc.  They usually cause little concern except for their ugly appearance, however, they can become large enough to bleed if traumatized and an episode like this can be very frightening. 

What do we do for spider veins??  The best way to handle them is with sclerotherapy.  Now that may sound scary but really it is pretty simple.  We inject the veins with a chemical that causes them to stop working.  Sometimes a small clot forms in them and over time, your body resorbs the clot and vein eliminating the problem.  The process is fairly easy, quick, and causes minimal pain.  We have you wear a tight (compression) stocking for about two weeks after the injections and after that....nothing.  You may have some areas of pigmentation in the area for a few months and this usually resolves without further treatment.  Because this problem is superficial, most insurances consider this treatment Cosmetic and will not cover it under the usual policy.  We charge $350 per treatment and a treatment consists of two vials of the solution we use which is the safe amount at one sitting.  If more treatments are required, we usually wait about 6 weeks before re-treating.  Small areas usually require only one session.  Big, or multiple areas may require several sessions.

For a little larger veins we call reticular veins, we still use the sclerosing solution.  Sometimes it is used in a higher concentration and we use an instrument called a vein light. 

The vein lite allows me to see the larger veins under the skin that fill the small spider veins on the surface.  This instrument produces a very bright, circular light that produces no heat and is very good at showing reticular veins as you can see from the picture above.  I can then inject them with the sclorosing solution, stop the blood flow, and with time, the vein is eliminated by the body.  I usually try to find and eliminate any of these veins at the time I do the routine sclerotherapy.  Again, stockings should be worn for two weeks after the therapy and strenuous exercise is avoided for two weeks as well.  This helps in preventing future spider veins originating from this one source at least.  

Maintenance may be required when treating spider veins.  They usually sneak back into your life after a few years, even if all of them are eradicated along with the reticular veins.  I like to recommend that less is more....in other words, if we treat a large amount the first series of treatments, it is a lot easier to keep up by treating small areas as they arise.  Don't let them get out of hand again.

Varicose veins treated the modern way, with laser, require minimal down time and are done in the office.  It usually takes about 3 months to get insurance approval so you need to start now.  If you have varicose veins that are ugly, hurt, cause leg swelling, and create embarrassment....come see us to get started on effective, easy treatment today!!!

varicose veins.

Call 918-786-7780 or 1-877weight0.

  If you have not looked at this offer in the red box....you may be missing out on the opportunity of a lifetime!

What does skin cancer have to do with you?  Quite a bit actually.  Skin cancers are the most common cancers and that is when compared to ALL other cancers.  There are 3.5 million skin cancers diagnosed each year and another 77,000 cases of melanoma.  The incidence of all types of skin cancer are on the rise for an unknown reason.  One can speculate however, i.e., tanning beds, less coverage of skin with modern fashion, changes in our atmosphere, etc., etc.  But nobody really knows why.

As you can see from this graphic, this is a common problem.  Of course, there are several types of skin cancer that are common.  There are types that are not as common.  Then there are very rare types that are beyond the scope of this discussion.

Let's talk about the most common types first.  Basal cell carcinoma's are the most common types of skin cancer.  As the name suggests, this type of tumor arises from the basal layer of skin and is associated with UV or sun exposure.  This type of skin cancer comprises about 2.8 million of the 3.5 million skin cancers occurring in 2012.  These tumors very rarely spread to lymph nodes or other organ systems.  They start off small...

 are often ulcerated with raised edges.  Like a sore that never goes away.  They usually only spread locally and can become quite large if left alone...

  They can locally invade through bone and can require extensive surgery to remove.  It is therefore wise to seek advice while these lesions are small and easily removed.  We usually remove them surgically but they can also be removed by a Moh's procedure.  After complete removal the tumors rarely come back unless there are multiple areas involved (multi-focal tumors).  Also, the sun damage that caused the original tumor is also present on other exposed areas.  Therefore, once one is removed you must be diligent to identify and remove other tumors.

The second most common tumor, accounting for about 700,000 cases, is squamous cell carcinoma.  These tumors arise from the superficial layer of the skin and are also associated with sun exposure.  Squamous cell carcinomas involve the most superficial layer of skin.  They are usually scaley, thinner tumors in sun exposed areas.  Unlike basal cell cancers, these tumors can spread to lymph nodes in about 2-3% of cases.   This is why removal of these tumors early is a good thing. 

The big daddy of skin tumors is the melanoma.  It arises from the pigment cell in the skin called the melanocyte.  These tumors can be nasty.  About 70,000 of these tumors were diagnosed in the U.S. last year and it seems that it is on the rise.  Melanoma can spread about anywhere.  From the brain to the eye, spread of the disease is a tough problem.  These tumors can occur any place in the body that has pigment cells.This picture is pretty classic for a nodular type melanoma, irregular, varied color, and a nodule.  They can, however, look like a normal mole.  Any pigmented lesion on the skin should be watched for change or increase in size.  Treating melanoma early is critical to survival and recovery.  Early treatment means less chance of spread to other places.

There you have it, a quick primer on common skin cancers you need to look out for.  Come see us for these problems and we can help.

918-786-7780 or 1-800-weight-o.

Re-do what?  I have lots of patients that ask about how long a cosmetic procedure will hold up or "last".  I think that is a fair question in most instances.

First, the face.  When people ask me the question before a facial procedure, the analogy I like to use is daylight savings time.  When you have a facial procedure, basically, we are resetting the clock on your appearance.  You will continue to age, just like time continues to tick away in daylight savings time.  In other words, the change is permanent, but aging continues to change your appearance.  The procedure most often repeated is eyelid surgery.  Eyelids move constantly, the skin is very thin, and the eyelid skin is exposed to a great deal of sun.  The nature of the skin is to stretch and when used a great deal, it will stretch more.  Upper and lower eyelid surgery, the second time, is usually less traumatic than the first time because the fatty tissue has already been removed.  That means that only the skin is removed in the second procedure.  The second procedure most often repeated is the facelift.  Again, after the first procedure, as we continue to mature, the skin continues to stretch and the floppy neck or jowel may return after 15-20 years.  A second face lift is easier because of scar tissue that forms gives us more tissue to work with so sutures hold better and dissection is less involved.  The procedure that holds up the best is the endoscopic brow lift.  Since the low brow is usually heredity related, once the brow is lifted it tends to stay put.

Second to discuss are body procedures.  Tummy tucks seldom need re-doing unless you have severe changes in weight or have a pregnancy after the initial procedure.  That is why we encourage women to be done reproducing before considering a tummy tuck.

The same is true of most other body procedures, thigh or butt lifts, arm reductions, etc.  Liposuction is seldom repeated in the same area except for touch-up prodedures since most of the fat cells in that area have been removed.  Of course, if you do gain weight, it will appear in other areas and the repeat procedure will be in that area instead of the old site.  In other words, if you have your abdomen done then gain 20 pounds, you may notice that your arms or thighs are where the weight is going.  The reason is, the fat cells that used to store fat in the abdominal wall are gone or greatly diminished in number and fat can no longer be stored there...it must go somewhere else.

The third is the breast.  This is a whole other animal sorry to say.  The breast is somewhat unpredictable.  For breast augmentations, they look great in younger women and generally hold up well with two caveats....pregnancy and weight changes.  Most women look fantastic with their breast implants... until pregnancy.  Then, in some, the wheels come off.  The breast inlarges during and after pregnancy, breast feeding occurs, and for some, the process repeats itself over and over.  After several pregnancies and several years the breasts start looking sad.

They droop over the implants or sometimes take the implants with them.  In these cases, the only solution (after a tubal or vasectomy) is a breast lift, removing the old implants, and deciding whether to replace the implants or not.  The only way to get fullness in the upper part of the breast in this situation is with an implant so it just depends on the final outcome you are looking for.  Of course implants can always be placed later.

Hope this helps answer your questions and don't forget all of the special pricing we have going on with hair removal, tummy tuck, and weight loss surgeries!!

Call for complimentary cosmetic consultation 918-786-7780 or 1-877-weight-0.  We can't wait to hear from you!

  Do you ever feel like this?  What is a brow lift and when do I need one?  How do you know if it's the eyelid or the brow?  This week I hope to give you the information you need if you have these questions, or know someone who does.

  Many people show up to the office wanting their eyelids done.  The eyelids droop, look bad, and sometimes even effect their vision.  The question is..this, is it the brow, the lids, or a combination of the two?

If you look closely at this picture, what do you see?  First, it looks like her lids are drooping.  On closer inspection, the problem is a little more subtle.  If you look at the brow position, it is very low.  There is a hood over the outside of the eyelid and out over the outside of the eye.  This is a tell-tale sign....lateral hooding.  The second thing you notice is how low the eyebrow is in relation to the eye.  In females, the normal position should be above the boney rim of the upper eye and should have an arch to it that is highest at about the outer iris (colored part of the eye).  Her brow is far from being in the proper position...it is very low.  She may come asking to have her eyelids fixed, and without further examination, she may be right, but the primary problem is her brow.

Brow ptosis, or droop, is a problem that can be multi-factorial.  It is partially hereditary and is added to, as a problem, by facial fat loss.  It can cause cosmetic issues, making you look older, tired all the time, and causes wrinkles in the forehead due to over-use of the muscles in the area so you can see.  Brow ptosis can also cause visual field problems.  Our peripheral vision is dependant on a clear field of vision, up, down, medial and lateral.  What the droop can cause is an occlusion to the vision.  Once the brow falls significantly, it is like having blinders on a horse, you can only see straight ahead!

In many cases, the brow droop is accompanied by upper lid laxity (blepharachalasia) as well.  When this happens, we try to address both problems at once.  For older patients with visual problems, we establish the problem exists first by doing a "visual field" test.  This establishes if your vision is actually effected by the extra or low tissue.  Then the lid or brow is taped out of the way and the test repeated.  This allows us to tell if removing eyelid tissue or elevating the brow is indicated, or if both are indicated.(Visual field testing.)

 This is a great example of an eyelid problem only.  If you look closely you see that the brow position is exactly as we discussed.  The brow is in a good position as far as it relates to the boney part of the eye socket, and it is arched nicely.  Also note that there is no lateral hooding present as we saw in the previous picture.  It is the eyelids that are the problem and a simple blepharoplasty is sufficient to fix this.  This is a great result by the way, off of google images.

 A blepharoplasty means removing skin from the upper eyelids and often a small amount of fat.  This gives you back the lid platform for eye make-up, makes you look less tired, and is very rejuvenating, knocking several years off of your appearance.  I usually do these in the office, mostly under local.  It takes about 45 minutes or so, you go home after, there usually is no more than minor bruising, and after healing several months, you can't even see the scar.  It is a great procedure.

When a brow lift is done for cosmetic purposes.  I do them using a scope and a camera.  Some people still make a large incision on the scalp but I think the scope gives great results without significantly moving the hair line and without a big scar.

This picture depicts where the small incisions are placed for a brow lift.  We shave no hair, the hair line stays the same, and the results are just as good as the old big incision.

This shows a nice result from a brow lift.  She looks much younger and the hoods that she had before are now gone.  The brow position is arched and good...no surprised look.

If you are dealing with these problems, come see us today at Total Body Surgical.  We can help...call 918-786-7780 or 1-877-weight-0.