This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.
Losing a large amount of weight can be life-changing, but it can also come with some challenges. Hi, I am Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Dr. Peter Rubin. He’s the chair of the UPMC Department of Plastic Surgery and the director of the UPMC Life After Weight Loss Program. Thank you so much for joining us.
– Thank you so much. It’s a pleasure to be here with you today.
– This is really such an interesting topic. It is such an accomplishment for folks to lose a large amount of weight, but then there do come some challenges afterwards.
– There certainly are challenges afterwards. And, without question, the hard work, the dedication, The commitment that people have put into losing a large amount of weight is so admirable. And we are such fans of this accomplishment that our patients have been able to undertake. After weight loss, many patients will have problems with excess skin. And, this excess skin, the patterns are very variable. It really is different patient-to-patient. It depends a lot on their age, their natural skin elasticity, their body type to start with, how they’ve decreased or changed their body composition in different areas of their body. There are a lot of factors that go along with that. We have been very privileged to take care of the weight loss population in Pittsburgh for more than two decades now with our specialized services with the Life After Weight Loss Program.
– And when you talk about excess skin, there are both physical problems that can come along with that, and some psychological ones. Talk about that.
– Absolutely. So, let me start with the physical problems. So, excess skin in itself, especially when patients have an overhanging apron on their belly that we call a pannus, that can cause constant irritation, chronic skin infections, a lot of problems with hygiene. That is a very common thing that we see in our practice. There can also be problems with loose skin in other parts of the body that will cause rashes, irritation, and discomfort. On a broad scale, many patients really consider the plastic surgery phase to be part of that weight-loss journey because the excess skin is sort of a daily reminder of the former obese state that these patients were in. And, a lot of people will make this a priority to talk about taking care of this excess skin.
– So, you mentioned 20 years, you’ve been doing this. Tell me about how this program came about, how this center came about?
– When I was in my residency training in the mid to late ’90s, we started to see more and more patients who were coming in with problems of excess skin after weight loss. And this was at a time when the number of bariatric weight loss procedures was really going on the rise. And, this was sort of a new thing to see patients in these large numbers coming in. And I took on a great interest in helping this population. And, I noted that there was very little in the plastic surgery literature that had been described about how to take care of all of these different issues with excess skin, from making sure we can do this safely to developing new procedures, to really taking into account the needs of this patient population. And, I came to Pittsburgh in 2002 with the intention of starting this specialized program, Life After Weight Loss. We were one of the first dedicated programs in the nation for plastic surgery after weight loss. And, our goal was to do this well, to do this safely, to really be on the pioneering edge of coming up with the best treatments to help our patients. That’s how this all came about. And, over the last 20 years, we’ve taken care of so many patients in the region and beyond. We have patients who travel in for these services, and we have prided ourselves on making sure that we are on the forefront of the procedures being developed, that we’re doing things safely, that we’re really understanding the needs for our patients and offering them the best possible care.
– And, so, what does a timeframe look like this? How long after someone loses a significant amount of weight is it time to come and see you? Is it right away? Do you wait a year? What does that look like?
– That’s a great question. So, there are a couple of factors that go into the timing. First is, weight stability and time from bariatric surgery. If patients have had a bariatric surgical procedure, we want to make sure that you plateaued, that you’ve hit your goal weight, and that you’re maintaining that weight. That generally takes about 12 to 18 months after the bariatric surgery before patients hit that plateau and they can maintain that weight for at least three months. So, we don’t want people to come in while they’re still actively losing weight because we don’t know where they’re going to end up in that process. Also, your body is very much in a negative catabolic balance, where their bodies are shedding this excess weight, and it’s not a great time for wound healing. It’s not a great time to talk about surgery. So, we want you to be weight stable. We want you to be at a plateau as close to your goal weight as possible. Now, for patients who have lost weight through diet and exercise, we’re seeing more and more of those patients, especially with some of the new medications that are coming out to help with weight loss. Once again, we want people to be as close to their goal weight as possible, and to be maintaining that weight for at least three months to make sure that their weight’s stable.
– So, what does it look like when someone comes to see you? Who’s at the table, and how do you determine, “You should get this procedure,” or “You should get that procedure”?
– One of the most important principles in plastic surgery after weight loss, is that we have to understand the patient’s individual priorities. They may be focused on an apron of skin on their abdomen, they may be focused on excess skin on their arms. But regardless of what they are focused on, the important thing is that we, as the physicians, are going to pay very close attention to what the patients are focused on and what their priorities may be. And, we work with our patients to try and have them list out those priorities, and it’s a good thing for patients to think about before they even come for the first consultation because we want to meet the needs of our patients. And, there’s not a set array of procedures that patients necessarily need. In fact, most patients who come in have issues with physical discomfort of the skin, but it’s not for us to dictate, as the surgeons, what procedure should be done.
– Obviously, it would depend upon the patient, depend upon the procedure. But, what does surgery look like? What’s a recovery time look like?
– Sure.
– What do you want folks to know?
– A lot of times, there’s this misconception that these are just, you know, little “skin tuck surgeries,” but they are real procedures that are done in the operating room with anesthesia. We have an expert team of anesthesiologists that work with us. We have an expert team of surgeons in the room with us. But these are real surgical procedures. For a basic, more common procedure, like a panniculectomy or an abdominal plasty, and we have many different versions of this operation. It’s another important point, is that we custom-tailor the operation for each patient. It’s not one size fits all. The operation itself is generally going to take about two to three hours, and the recovery for this will involve about four to six weeks of no heavy lifting. If people have desk jobs, they’re able to get back to desk jobs in as little as two weeks. Some people choose to take more depending on the nature of the recovery. And for people who need to get back to the gym to more heavy work or heavy exercise, that is about four to six weeks.
– So, I know, and we’ve talked about this, when it comes to body contouring, it can mean so many different things.
– Yes.
– And you touched on this. You have really pioneered some procedures and techniques that are now used by surgeons around the world. And, let’s talk a little bit about some of those.
– Certainly. So, one of the signature procedures, if you will, that we developed here, is a procedure to reshape the breast after weight loss. And, many patients who undergo significant weight loss will have a loss of volume in the breast. They will have stretching out of the skin envelope of the breast and a shape that they’re really not happy with. And, what we learned early on is that most of these patients do actually have enough volume in their breast to work with to get a good shape, but we needed to be very creative about how we could rearrange the tissues, how we could work with the tissue surgically to literally create an internal brassiere that would support the tissue of the breast and give long-term stability to the shape. And that’s an operation that I’ve been lecturing about literally around the world for a couple of decades now that is really considered one of the gold standard operations for reshaping the breast after weight loss. Another thing that we learned in that process is that patients who have undergone weight loss and have loose, stretched-out skin don’t do very well with breast implants. They tend to have a lot of pull from gravity, and they can sort of drop out and change the shape of the breast in a way that patients don’t like over time. That’s why procedures that use a patient’s own natural breast tissue are very much preferred. That’s one operation. Another operation we developed early on in our experience was a method of correcting tissue in the back, skin folds in the back of the patient. And, being able to develop an operation where we could place the scar in the brassiere line, or in a way that’s hidden by clothing, and could really smooth out the tissues of the back.
– These surgeries are for men, too, correct?
– Absolutely. And we take care of a lot of male patients. Of course, they have different goals for the chest reshaping. They often have extra tissue there, and we need to get a flatter, more masculine shape for those patients. So, we have procedures that we do that can take care of that as well. And, I absolutely want our audience to know that this is an area where we literally work from head to toe. We have procedures for every part of the body that we’ve developed over the last couple of decades, and we can talk about literally any aspect of a person’s body, from the top of their head to the tip of their toes.
– Obviously, everybody’s insurance is different. I’m wondering if some of these procedures can be covered by insurance? And, if not, can patients still get these done?
– Different insurance companies will have different criteria for meeting those needs in terms of medical necessity. But we help our patients through that process. And we help them – wherever we can get insurance coverage, we will help our patients fight for that and try to gain that coverage. The reality is that many of the procedures that we talk about, unfortunately, are not covered by insurance, but we make sure that those rates that the hospital charges for those procedures are in a reasonable range. There are mechanisms for financing for these operations for patients, so they’re still very attainable even though insurance may not cover all of these.
– Talk about what you want people to know about your approach and how you approach patients.
– As I mentioned before, the primary focus of my approach is to understand the goals and priorities of each individual patient because they’re going to be different patient to patient, and we want to understand that. And, we want to make sure that we are meeting the individual needs of every patient who comes in. And, when we frame the conversation about what procedures might be suitable for them, it’s always in the context of understanding their goals and their priorities as a foundation, as a starting point. The second principle is that safety is absolutely paramount. And, for many people who lose weight, they may have some residual medical problems. They may be smokers. They may be using tobacco products. They may have some factors that can be optimized prior to the procedure. They may even need to go back on an aggressive diet and try to lose a little bit more weight to get their body mass index or their overall body weight better optimized so they have better results from the procedure. So, I warn a lot of patients, “Please don’t be upset if we tell you this is not the right time to have surgery, but we’re going to help you on this path to optimizing the factors that are going to give you the best results and are going to make this as safe as possible.”
– And you’ve touched a little bit on this before. Tell me about the staff you work with and what you want folks to know about them.
– We have a dedicated team that works with myself and Dr. Gusenoff, my partner in the Life after Weight Loss Program. And these people are specially trained to understand the elements of the medical history in a patient who has lost weight, to specifically maximize safety, look for the medical issues that may interfere with safety, and understand how to optimize those. We also pay a lot of attention to your current nutrition. Where are you getting your protein from? Are you on supplements if you have had bariatric surgery, and may have problems with absorbing different nutrients? So, the team is specially trained to look for the specific factors that are going to help our patients successfully get through these procedures.
– What do you love most about your job? What’s a good day on the job for you?
– A good day on the job for me is working with people who, through dedication, and courage, and a great positive attitude, have changed their lives through this process of weight loss. And, I love hearing the stories about how different their life is after having lost weight and all the things that they can do that they could never do before, how proud they are of those accomplishments. And, being part of that weight loss journey, helping them through understanding what procedures might be available for them. That’s with our new patients. With our established patients who are coming back for follow-up visits, I love hearing about how well they’re doing after the surgery, how the surgery that we have helped them with has improved their lives, and made a big difference, and been a great complement to that weight loss journey, and in fact, been part of that weight loss journey. So, I love having that positive impact on the lives of my patients and helping them through this great process.
– Dr. Peter Rubin, we thank you so much for coming in and spending time with us today. Some great information. We thank you for your time.
– Thank you so much. It’s a pleasure to be here with you today.
– I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.