You Lost Weight, But Now You Look Like a Melted Candle

Announcer (00:09):
Welcome to another episode of The La Jolla Cosmetic Podcast with your host, Monique Ramsey.

Monique Ramsey (00:17):
Ever looked in the mirror after major weight loss or pregnancy and thought, where do I even begin? Loose skin on your stomach, thighs, arms, and butt can feel overwhelming. And Googling body lift only adds to the confusion. So we're going to talk today with Dr. Johann Brahme. He does a ton of body lift work, and we're going to break it all down. We're going to find out should you do it all at once? Can you do it all at once? And how do you decide what comes first? So welcome Dr. Brahme.

Dr. Brahme (00:47):
Thank you, Monique.

Monique Ramsey (00:49):
Alright, let's start with the basics. So when somebody says, I want a body lift, or when somebody tells you, what can I do here? What does that typically include? And who's a candidate?

Dr. Brahme (01:02):
Okay. Well, this is a big subject because basically it's all about tailoring. And most people who come in for a body lift don't say that they're coming in for a body lift. I always start by asking the patient, what's the most important thing to you? And we go down the order of importance of what they want to have done. And some people want to do the stomach first. Some people want to do the breast first, some people want to do the thighs first or the face. So it's really a global sort of pan body endeavor. So what do you do? Well, I try to first assess the patient's health, and some people are very anemic after, especially after gastric bypass surgery, so we have to boost their blood count. And I've had patients who've had to have iron infusions to get their blood count up because some of the gastric procedures prevent uptake of iron and so on. And so they're chronically anemic. Most people, I tell them to start with a stomach because when you do the abdominal and sometimes the flank in the back surgery, they will lose weight after that. So they may lose another 10, 15, 20 pounds, which changes the face, which changes the breast, which changes the thighs and the arms and everything. So I usually like to start with the abdomen.

Monique Ramsey (02:39):
So if we talk about the midsection and there's an extended tummy tuck, but did that only maybe wraps around to the flanks? And I've heard the term belt lipectomy, is that just like all the way around?

Dr. Brahme (02:53):
A belt is all the way around, just like the name suggests, it's a belt that goes all the way around. And that's really for people who have lost a lot of weight and it tends to heal very well. We could keep the scar nice and low, and it's a very good procedure. It takes about two weeks or so to really start the recovery from that. And by four to six weeks you can usually do pretty much anything you want.

Monique Ramsey (03:22):
How long would you want their weight stable before they have a surgery?

Dr. Brahme (03:30):
Oh, I think that probably a couple of months is fine. You certainly don't want to do anything in the middle of a weight loss program. But once they're stable for a couple of months, that's usually enough. Although I have some people who come in and they've been stable for a year or two, but more than a couple of months I think is a good idea.

Monique Ramsey (03:55):
What would be the thing, I guess there are maybe three things that would prevent somebody from being a good candidate moving forward with a surgery?

Dr. Brahme (04:04):
Well, I think if they have a systemic disease that's out of control, for example, diabetes, if that's not in good control, if they have a heart condition, if they've had a ton of abdominal surgery, that might not lend itself to doing abdominal tightening. And then things like anemia that we can usually correct, it's really a matter of general health.

Monique Ramsey (04:32):
So really it's not necessarily like if the patient thought, okay, if I want my midsection, I want my thighs, I want my arms, my breasts. Is it more determining how many procedures or does it come down to time in the OR?

Dr. Brahme (04:49):
Well, both. It's not really the number of procedures. I mean, we could do a little liposuction, do a brachioplasty for the arms and do a tummy tuck and various combinations. So it's not the number of procedures. It's really their general health and how long is it going to take in the operating room. And I'm a pretty quick surgeon, so we limit ourselves to no more than seven to eight hours of scheduled surgery. And doing that, you can usually fit in the tummy and the breast and maybe the arms or the tummy and the face. I don't like to do the abdominal part and the thigh part at the same time because it causes a lot of swelling in the pubic area, and that swelling takes a long time to go down. So I prefer to do the tummy and the breast, the tummy and the face, the tummy and the arms, that sort of thing,

Monique Ramsey (05:47):
And save the thighs for later.

Dr. Brahme (05:48):
Save the thighs. Thighs are the last, I think, for most patients because it's a pretty long recovery.

Monique Ramsey (05:54):
Now, if it's a staged procedure, let's say we're going to do the tummy in the face and then we're going to do the breasts and the thighs or whatever is decided. How long in between surgeries do you like to have? Six months or is it a couple months or a year?

Dr. Brahme (06:11):
I would say a minimum of three months, but I'd be more comfortable with four to six months probably.

Monique Ramsey (06:20):
So if we talked just specifically about, let's say the tummy tuck or a belt, like a 360 really, because going around the whole

Dr. Brahme (06:27):
Going around the whole body,

Monique Ramsey (06:29):
Yeah, you're tightening

Dr. Brahme (06:30):
Some people think we cut 'em in half, but we don't.

Monique Ramsey (06:34):
So you're kind of trying to get rid of all that extra skin. And is it possible to sort of create a waistline?

Dr. Brahme (06:42):
With extended tummy tuck and with belt lipectomies, you get a very nice waistline. You get that hip narrowing that really you can't get any other way. Not even with a standard tummy tuck, because that doesn't really address the hips. So I used to do probably 90% standard tummy tucks. Now I do probably 70% extended tummy tuck so that we can get that nice curvature of the hip. And it really is a marvelous operation. And the only difference between that and a standard tummy tuck is that the scar is a little bit longer, but the scar is long anyway. I think that for the improved results, the extended tummy tuck is really great.

Monique Ramsey (07:30):
As we lose weight our skin, and as we age

Dr. Brahme (07:34):
And as we age.

Monique Ramsey (07:34):
Our skin is more lax, I'm thinking about the buttocks now. If it was a belt and do you pull up, do the buttocks get a little love in there?

Dr. Brahme (07:42):
Oh yeah, you, get a little butt lift from that. That's absolutely true. And that's what some people are looking for too. But it's a nice little bonus because you really get your abdomen very nice and flat for most people.

Monique Ramsey (07:58):
And the recovery for that would be, like you said, a few weeks. And are there drains involved?

Dr. Brahme (08:04):
Oh yeah. We do have drains for the belt and the extended tummy tuck. There are four drains, and for the standard tummy tuck, there are two drains and they usually stay in between one week and two weeks. And they are a hassle, but they are necessary and they really cut down on fluid collections after surgery. So they have their purpose, but people still like to be rid of them as soon as they can. And I do too. I do too.

Monique Ramsey (08:32):
Yeah. Yeah. Now, we had one of your patients on the podcast. I can say her name because she's come on the podcast, Kathleen Lisson.

Dr. Brahme (08:41):
Oh, Kathleen.

Monique Ramsey (08:42):
And we talked about lymphatic drainage, massage and therapy. And so tell me what, and I would think, I'm guessing that for any kind of body lift, whatever combination, having that fluid helped along, by some massage is a good thing. What do you think about it?

Dr. Brahme (09:02):
I love lymphatic massage. I think it really mobilizes the fluid in the tissues and it softens things up. And Kathleen is really the master at doing the lymphatic massage, but I love massage. I think lymphatic massage is wonderful because you do cause a lot of swelling and you interrupt the lymphatic vessels. And what Kathleen does is mobilize that and get the fluid out of the tissues and she'll show the patients how to do it themselves too, which is really nice.

Monique Ramsey (09:35):
Yeah, and we'll put that in the show notes with a link to that episode because

Dr. Brahme (09:39):
That'd be great.

Monique Ramsey (09:40):
It's really, really helpful. Let's move up the body to the arms. And you were talking about a brachioplasty or an arm lift. It's that kind of batwing appearance that nobody wants to have. So what causes that? Is it just that the skin is stretched from being heavy and then you're just left with a lot of extra?

Dr. Brahme (10:01):
Yeah, that's basically it. The same reason as the stomach and the thighs is that there was fat there. Now that, and the arm was thick and now they've lost the weight, and now it's just a skin hanging. If it's just an isolated thing with the arms and say somebody has heavy arms and the rest of 'em is normal, we can do liposuction and that's very helpful. But once the skin has lost its elasticity, then you need to tighten the skin. And the brachioplasty is a scar that goes from the elbow right here at the elbow goes along the muscle here, the biceps muscle, and then curves into the armpit. You do have a drain for that. That drain stays in for only about two or three days. As with all these procedures, it's tailoring and you're going to have some scars and you need to accept that. And the scars usually heal very well, but they are there and they will be visible.

Monique Ramsey (11:03):
How long would a recovery from a brachioplasty take?

Dr. Brahme (11:07):
Oh, a couple of weeks. I mean, in terms of exercise and so on, I would probably say upper body exercises at least a month. But you can do pretty normal things after a couple of weeks. The brachioplasty is not that invasive and it's not that painful.

Monique Ramsey (11:29):
Really? Okay, good.

Dr. Brahme (11:30):
I've even done that under local anesthesia on a patient who insisted and she did just fine. So I don't recommend that. I don't think that that would be my choice, but she insisted, and so we did it under local.

Monique Ramsey (11:48):
Now, could you combine the brachioplasty with the breast if the breasts are being lifted and all that scar, can you make one big happy procedure?

Dr. Brahme (11:59):
Yeah, usually the scar from the breast, it goes underneath and sometimes we can sort of just continue that incision up under the arms so the breast and the arms go very well together.

Monique Ramsey (12:12):
Now getting back to the thigh lift, what parts of the thighs does a thigh lift target?

Dr. Brahme (12:19):
Well, there are two types of thigh lifts. There's the standard thigh lift and then there's the extended thigh lift. The extended thigh lift is sort of a chevron scar that goes along the crease of the groin and then down the inner portion of the leg down close to the knee. So you get both a circumferential tightening and a lift at the same time. I think that's a great operation. It takes about four hours to do. It does something that nothing else can do. It gets rid of that skin and looseness in the thighs. There's also another thigh lift, which just takes out a crescent from the upper thigh. For those who have better skin tone and just need, don't need as much tightening, but both of them take a while to recover from. Because the scar, it's in the groin, it's in a moist area, and there's a lot of motion at that. So we have the patients be pretty, pretty quiet while they're recovering from that.

Monique Ramsey (13:26):
Yeah, I was thinking mobility might

Dr. Brahme (13:28):
Mobility is a little tough with a thigh lift, but the people who have a thigh lift are ecstatic about the results because the results are, if you go through this, the results are amazing.

Monique Ramsey (13:40):
I know we have Renuvion, which is sort of a tightening device. Can you ever use that in conjunction with anything down there?

Dr. Brahme (13:48):
I use a Renuvion mainly in the back when I do liposuction. I don't like to use it when I have incisions because it can burn and it can cause some problems because it's really about skin tightening. So you're injuring the skin from the underside and with the surgery, you're injuring the skin from the top side. And I think it's a little risky to do that now.

Monique Ramsey (14:16):
Okay. We talked about belt, we talked about arms, we talked about thighs. And so the breast is a breast, do you call it a lift or a reduction when you've got a whole bunch of extra skin, cuz the incisions are similar?

Dr. Brahme (14:30):
Yeah. Breast reduction is mostly removal of breast tissue, which we'll send off to the pathologist to have a look at, make sure there's no breast cancer or anything. A lift is more skin contouring, and most patients benefit from an implant as well, because with large weight loss, sometimes the breasts are really deflated and you really need to lift them up and put an implant in to give them that fullness and the proportion that they have to the rest of the body and everybody wants to look proportional. That's really one of the major goals of this.

Monique Ramsey (15:13):
Now, if we talk about what, and everybody's definition of normal is different, but how long in general for any of these body lift procedures would it take for them to look normal?

Dr. Brahme (15:28):
Oh, I think they look normal, you know normal, vastly improved. You can see the change immediately. I mean, it's not subtle. For some of these patients, we take off 10, 15 pounds and it's in targeted areas. So when you take the dressing off a tummy tuck or a belt, you're going to see a result right away. Same is true for the breast. Same is true for the arms. Same is true for the face. So you see an immediate dramatic change.

Monique Ramsey (16:06):
Would you say if somebody, let's say they're younger, they've gotten all these things done and gotten all tightened up, what if they gain 20 or 30 pounds? What's going to happen?

Dr. Brahme (16:16):
Well, that's why I want them to be stable for a while so that that's not going to happen. And it's truly the journey for them in terms of their weight loss and body change that has been so much work for them that I really don't see very many people who gain a lot of weight after this. They've worked so hard and gone through so much that it's unusual. I think that everybody has that concern, but if you gain 10 pounds or something like that afterwards, it's not going to destroy the results. It's not.

Monique Ramsey (16:54):
Okay. Now, we've talked a little bit about younger patients a lot of times have done this, but what if somebody's in their mid sixties or they're 70 years old, is it still appropriate for them to have this type of surgery?

Dr. Brahme (17:08):
Yes. I think that the workup and the screening has to be a little bit more precise. And as we get older, our heart gets older or blood vessels get older. So make sure that they are healthy. And it's really not about the age, it's about the physiologic health of the person.

Monique Ramsey (17:28):
And what advice would you give to somebody considering maybe a staged procedure and feeling like if they're feeling a little overwhelmed?

Dr. Brahme (17:37):
Usually at the consultation we go through everything. Everything that's a concern for them. And then we try to suss out what is the main concern. I mean, if somebody comes in and I think, wow, you really should do something about that tummy there. And they say, no, people see my face and I'd like to do my face first. That's an important thing for me to know. And maybe we can do the face and the arms together or something like that and then come back and do the tummy and the breasts later on. So it's really about what the patient wants.

Monique Ramsey (18:16):
In any of these little combinations, do they need to stay overnight in a hospital or surgery center, or can they go home, or what do you recommend?

Dr. Brahme (18:25):
If the patient is in surgery for more than six hours, then we require that they have a caretaker overnight for the first night. And some people do it more than the first night. Some people don't have anybody to take care of them. There are various things, but over six hours in the operating room, we require an overnight stay, and it's usually an overnight stay in a hotel close by with one of our caretakers. It's an outpatient procedure, but we do require somebody qualified to take care of our patients if we go over six hours in the operating room.

Monique Ramsey (19:04):
And then compression garments. How long do patients typically wear a compression garment after surgery?

Dr. Brahme (19:12):
Well, compression garments are very important. I mean, they can't be too loose. They can't be too tight, and the body changes afterwards. So we give people two garments, one for the surgery and one when the swelling has gone down a little bit so that they can remain snug. We tell patients to wear them for six weeks, but a lot of patients wear them a lot longer than that. They just feel more comfortable having that security of a garment. So it's not unusual for patients at three months or something still wearing some sort of garment. And I tell them that you don't have to wear this big surgical garment for that long. You can go to Spanx or there's a whole host of over the counter type of garments. And also Amazon has an incredible selection of garments for the different comfort and so on.

Monique Ramsey (20:08):
Okay. And is your typical timeline for, let's say physical activity, what's the timeline for walking versus, because maybe some people, once they've had this weight loss, they've changed their habits and then they're really antsy and kind of paranoid to get back to whatever activities they were doing so that they don't lose that momentum. And so what are your rules around getting back into exercise?

Dr. Brahme (20:34):
Well, again, the rules are, they are strict but flexible. So everybody recovers a little bit different, but usually at about a month or so, you're not going to hurt anything. The drains are out, the sutures are out, whatever sutures we used, and if they feel like starting to take walks around the neighborhood, things like that, then that's fine with me. I think for people who are competitive, gym rats, probably six weeks, and then I tell them, listen to your body if it hurts back off. And for abdominal surgery, we don't want them to do any crunches or sit-ups or anything like that for at least six months because we tighten the muscles and we don't want those sutures to pop loose. But we see these patients very frequently in the first month, I mean at least on a weekly basis for the first month. And so we know when they're ready and we know when they're not ready. And so they get to know the nurses, they get to know us really well.

Monique Ramsey (21:40):
Now, the big I word, insurance, does insurance ever cover any of this kind of surgery?

Dr. Brahme (21:47):
Less and less. We don't do insurance in La Cosmetic Surgery. Sometimes in patients who have a really big abdominal apron that hangs down to their knees, they get infections and so on, that can be really quite serious in all that extra skin that hangs down. And insurance, in some cases will cover this, but only for the very most extreme excess, and it's only for the abdomen. They never cover the arms, they never cover the face. They might cover the upper eyelids, and they do not cover the thigh plasty either, the thigh lifts.

Monique Ramsey (22:34):
And what about the breasts? No?

Dr. Brahme (22:36):
They might cover a complication. If the patient has implants and the implants are ruptured, they may cover that. But insurance companies are getting tougher and tougher, and especially with all the bariatric surgery and the weight loss and the backlog of patients who want to have body altering surgery, they're not really covering much.

Monique Ramsey (23:04):
And this is why we have PatientFi and CareCredit that really helps patients to say, okay, I'm going to do it like a car. Think of it like a car, and I'm going to have a financing plan and pay a certain amount per month and be able to break it down that way because,

Dr. Brahme (23:21):
And that makes a huge difference for a lot of people because these all day surgeries and recoveries, it's expensive. There's no question about it. But our coordinators are great at getting this taken care of and getting them signed up for financing. That's really great.

Monique Ramsey (23:41):
Yeah, and just think if you put part of it on a credit card, you're going to get miles.

Dr. Brahme (23:46):
You're going to get miles.

Monique Ramsey (23:46):
Go somewhere with your new body. You could fly somewhere, somewhere you want to go. During the consultation process, the last wrap up here is how do you best show patients what you can do for them to get the result they're looking for?

Dr. Brahme (24:05):
Yeah, we have a great tool in the office called TouchMD where patients who've had surgery have given their permission for us to use their pictures in the office. And so we have some on the website, and then we have hundreds more in the office so we can show you pictures of people who look like you, people who've had the same operation and so on. So that's really helpful, and we go through that with everybody in a new consultation.

Monique Ramsey (24:38):
And do you have a protocol for scars that you prefer for the patients as they're healing?

Dr. Brahme (24:44):
Yeah. I mean, we keep the scars taped for six weeks or so, and then we start scar gels and scar creams and scar tapes for some patients. And then most people heal very well. Some people have some hypertrophic scars, and we end up doing some injection with steroids to try to calm that down.

Monique Ramsey (25:07):
So in terms of pricing, I know you don't deal with that, but when you have that consultation and you figure out, okay, let's start with let's say the breast and the arms and then the tummy in the face in stage two or vice versa, we will give a quote and then you'll have the hard costs. But on our website, prior to that, if you're just kind of curious, we do have a listing of all of the different ballpark price ranges, so we'll put a link in the show notes to that page because that does help you get your head wrapped around

Dr. Brahme (25:40):
It gives you a ballpark.

Monique Ramsey (25:45):
But once you have that consultation, then you know exactly what you're looking for can make a plan, and I think that's a really nice thing. Now, if somebody who's listening today doesn't live in the area, can you do a virtual consultation with them?

Dr. Brahme (25:59):
Sure. We do that. I don't operate on the basis of a virtual consultation alone, so if they decide that they want to go ahead, then they'll have to come in to confirm everything. Depending on what we're doing, they'll have to stay around for anywhere between three days for a minimal procedure to maybe two weeks for a bigger procedure.

Monique Ramsey (26:26):
Right, right. Our coordinator team, they're so good at helping.

Dr. Brahme (26:30):
Oh, they're great.

Monique Ramsey (26:32):
Helping you get the financing, helping you figure out if you're from out of town where you want to stay, or even if you live in town and you just want to not be at home for that first night and have that aftercare.

Dr. Brahme (26:42):
A lot of people do that

Monique Ramsey (26:43):
Nurse and be in a hotel away from the kids or just the,

Dr. Brahme (26:47):
Yeah, especially if there's small kids around. It's nice to just have that first night where you can relax and be a little bit fussed over.

Monique Ramsey (26:59):
Yeah, fussed over. I like that. Well, thanks Dr. Brahme. Did we kind of cover everything?

Dr. Brahme (27:04):
I think so. I think so. And whatever we didn't cover, people can come in and ask in person.

Monique Ramsey (27:12):
Right. Exactly. Well, thanks everybody for listening. Check the show notes and we will see you on the next one.

Dr. Brahme (27:18):
Thanks. Have a great day.

Announcer (27:23):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment, or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the Ximed Building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram @ljcsc. The La Jolla Cosmetic Podcast is a production of The Axis, theaxis.io.