Life After Body Lift: What to Expect

Monique Ramsey (00:04):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your host is Monique Ramsey. Today I have Dr. Johan Brahme in the studio to talk to us about body lift surgery, but specifically post weight loss and specifically the recovery of these kinds of surgeries. And so the first thing we'll do is find out what is a body lift, what part of the body are we lifting? So Dr. Brahme, give us a little overview of what areas typically do you see that patients who have lost some chunk of weight, whether it's 20 pounds or 80 pounds or a hundred pounds, where do they end up with extra skin that needs to be lifted?

Dr. Brahme (00:49):
Everybody's different. Some people have very dynamic and elastic skin, and when you have weight loss, it shrinks back to normal dimensions and that's lovely. But when we're talking about more the massive weight loss patients, patients who've lost a hundred pounds or some, I've seen patients who've lost 250 pounds, almost a whole person, and that skin, it just doesn't recover. It has overstretched, its elasticity. It just hangs and reams. And anybody who's had a relative or has had this, knows that skin just no matter how much you go to the gym, just doesn't go away. So where do we see the excess? We see it in the arms, we see it in the breasts, we see it especially in the tummy and the back, the inner thighs and also in the face. Although the face does seem to have better recovery potential. The patients who come in usually want to address all of these areas because they've done the big job, the big heavy carrying of losing this weight, sometimes by surgery, sometimes just with diet and exercise, and sometimes with the new injectables, which are very effective.

Monique Ramsey (02:14):
Right, the GLP-1.

Dr. Brahme (02:18):
Semaglutide.

Monique Ramsey (02:18):
Right. Semaglutide, tirzepatide.

Dr. Brahme (02:21):
Right. And we've had very good luck with that and we offer that in our clinic and we've seen some great successes with that.

Monique Ramsey (02:29):
They really work.

Dr. Brahme (02:31):
They really work.

Monique Ramsey (02:33):
And it's wonderful to know that if you trust us already with your health and your beauty and your confidence, that if you have some weight to lose the skinny shot through our own program with Dr. Haas is a great way. But if you've already lost that weight and okay, now you're trying to figure out what am I going to do? I guess in terms of the procedures, like if we're doing breast and maybe arms are needed, but also the tummy is needed, how many things can be done at one time safely?

Dr. Brahme (03:07):
Well, that depends a lot on patient's health. A lot of people are anemic after, especially after gastric bypass surgery, so that needs to be taken into account. And then just how big is the person? Some people are just built taller. I've done men who've been six five and have lost hundreds of pounds. And then we've done smaller patients. So it depends on how much anticipated time in surgery, because we try to keep our surgeries to less than seven to eight hours. So that's the most we'll go. And strategically we try to combine things that are within that timeframe or doable within that timeframe. And the other consideration is future weight loss because a lot of these patients will lose weight after some of these procedures. So for example, when you do a tummy tuck or a lower body lift, a lot of patients will lose additional weight. And so you want to maybe wait with some procedures until they've stabilized with that.

Monique Ramsey (04:24):
And speaking of stabilization of your weight, how long after somebody has lost weight, might they be a candidate to have some lifting done?

Dr. Brahme (04:34):
Yeah, I like for people to be stable for at least six months. Some patients will fluctuate up and down quite a bit, and you don't want to do it if they're still on the way down or if they're still fluctuating.

Monique Ramsey (04:49):
Okay. And then is there a BMI that's too high for this procedure?

Dr. Brahme (04:56):
That's really up to the anesthesiologist. The higher BMI that put you in, still the obese group will sometimes be rejected by the anesthesiologist, but we rely on them to guide us.

Monique Ramsey (05:09):
Now, Dr. Brahme, is there a limit to the amount of loose skin you'll consider for this procedure?

Dr. Brahme (05:15):
The most I've taken off somebody was 40 pounds, which is an enormous amount of weight. But the more weight there is to remove the higher the risk for wound complications afterwards. So if there is a tremendous amount of skin to remove, sometimes you have to do it in stages. But most of the time we can do at least the proposed procedures in one stage. And I usually like to start with the tummy. And then after that, maybe the breast and the arms, finally, we would consider doing the thighs.

Monique Ramsey (05:59):
So the thighs are sort of their own.

Dr. Brahme (06:02):
That's sort of the last thing.

Monique Ramsey (06:04):
Now, is this something that they need to stay overnight somewhere after having surgery?

Dr. Brahme (06:09):
Yes. Most patients will have them be taken care of by one of our caretakers, and usually they go to a hotel. We don't send people to the hospital anymore because the hospital is full of bacteria, and that's just not a place where you want to recover from cosmetic surgery. So it's safer really to go to a hotel. And then usually we have one of the nurses, or I'll go to the hotel the next day and check on them, because it's a big surgery, and to have them get up and come into the clinic can be a little bit difficult for them. But we do want them to get up and walk afterwards. So that's very important. So to get the blood flowing in the legs and so on and so forth. In terms of activity, we will want people to get up the next day. And it's really important to have good aftercare to have that really nailed down so that they don't go home to an empty house or anything like that, because they're usually drains involved and there may be dressing changes and they'll need help getting out of bed and so on. So the first week can be pretty challenging.

Monique Ramsey (07:24):
So this is important to have your after care, whether it's a nurse for maybe that first 24 hours, but then either a family member or a friend who's really there to help get you safely from your bed to the bathroom or to walk you around the house and somebody else if you've got kids taking care of the kids.

Dr. Brahme (07:44):
And that's a big deal for, because a lot of people have weight loss after pregnancy, and that means that sometimes they have very young children. So the postoperative care is really key for a good recovery.

Monique Ramsey (08:00):
Now, do you ever recommend the lymphatic drainage massage for these kinds of patients either before the procedure or after, or both?

Dr. Brahme (08:09):
I recommend it after the procedure. I think it's very valuable. There's always swelling afterwards, and I think that it's very helpful. And we are fortunate here in San Diego. We have a woman named Kathleen Lisson, who trains people in lymphatic massage and lectures all over the world. And she and I have been taking care of the patients for a long time together. So she's great and I recommend it for everybody.

Monique Ramsey (08:38):
Yeah, Kathleen is terrific. And in fact, just yesterday on her Instagram she was putting out, she puts out great videos about what can I do after surgery or before? And she was talking about vaping. Somebody was like, can I still vape? It's like, no.

Dr. Brahme (08:55):
No.

Monique Ramsey (08:56):
So tell us, Dr. Brahme, why nicotine is so bad and why, and vaping's not really a different probably than a cigarette or a patch maybe. So why is that important?

Dr. Brahme (09:10):
Well, nicotine has always been known to be very bad for wound healing. And that's because what the nicotine does is that the blood vessels shrink like this when exposed to nicotine. And so all of the healing that relies on that good blood flow is impeded. And you can have horrible wound complications if you do that. And that's whether you smoke cigarettes, whether you vape, whether you take patches, whether you use the gum. We really require people to be off any kind of nicotine for at least two weeks prior to surgery and at least two to four weeks after surgery.

Monique Ramsey (09:53):
Yeah, I would say if you're getting off of it before surgery, just stay off of it.

Dr. Brahme (09:57):
Stay off it. Yeah. What a great opportunity to quit, right?

Monique Ramsey (10:00):
Yeah, exactly. Don't mess up all this hard work that you've done to get yourself ready for surgery and then Dr. Brahme's doing to get your new body back. And so speaking of getting that new body back, how long does it take for people to feel like they look normal? And I'm sure normal is everybody's definition of normal is different, but let's say to be able to go out and walk around the mall, or could they do that within a week or two?

Dr. Brahme (10:32):
Not within a week or two. I think that that's really optimistic. I would say that you can maybe consider after one of these big procedures going to a movie at maybe two weeks, better count more on four to six weeks. At that time, you can go to the gym, you can start lightly with exercise. But again, everybody's a little different. So I've had patients who at three weeks doing things that I would never expect them to do. And I've had patients who at eight weeks are still asking for more pain medication. Everybody's different in terms of their strength, their endurance, pain threshold, and we address all of those and we're not going to cut somebody off for pain medication. We give people what they need, but we also encourage them to listen to their body. Your body's going to tell you a lot of useful information about what's your limit and don't try to push beyond it. Just go and listen to your body. That's probably the best advice that I give people afterwards.

Monique Ramsey (11:45):
Now what's the first thing when they come back, let's say a six week and they're back in the office, what do they say when they see that kind of new self for the first time?

Dr. Brahme (11:57):
Oh, I've had people break down in tears. It's really life altering. I mean, this is something, they did all the heavy lifting with the weight loss, and then we did all the tailoring. I've had patients just give me hugs and tell me how they're planning to go back ballroom dancing, they feel more confident, things fit better. They can wear clothes that they hadn't worn for years. So it's a really life altering procedure.

Monique Ramsey (12:34):
I'm assuming men are in this group as well. Men can lose a lot of weight. And where does most of the extra skin for men end up? Sort of in the same places for women, maybe the breast and the tummy?

Dr. Brahme (12:46):
Most of it ends up in the tummy. And I would say that the proportion of men that I see is probably maybe 25%, something like that. But it's just yesterday I saw a patient and he was six foot three, and we need to do his breasts, we need to do his tummy. Maybe eventually we'll do his thighs as well. But it's very, very similar. When you're talking about that amount of extra weight, the distribution is very similar.

Monique Ramsey (13:21):
Let's say it's in the two stages. So say you start with the tummy, then you are ready to do maybe breasts and arms for someone. How long do you make them wait in between procedures?

Dr. Brahme (13:34):
I think it's probably good to wait at least three months because it takes a while for the scars to heal, for the swelling to go down. I think for them to sort of rebuild up their stamina and their red blood cell volume. I would not crowd the surgeries too much. This is elective surgery and it should be done very safely.

Monique Ramsey (13:57):
You mentioned incisions and swelling. So kind of for the incisions to heal, how long is that and to be considered healed?

Dr. Brahme (14:07):
The incisions are definitely healed by two or three weeks, so you can't sort of stretch and reopen them prior to that. If you have a fall or a slip or something like that, you can split open, but that's really unusual. But by three weeks you're pretty well healed. Now the scar isn't matured because it takes really several years for the scars to sort of be what they're going to be forever. Scars and fine wine are things that improve with time.

Monique Ramsey (14:43):
I like that.

Dr. Brahme (14:46):
The scars keep getting better, and we have all kinds of creams and we tape the scars in the beginning so that they'll stay as flat and narrow as possible. I do the same closure on everyone. Some people make beautiful scars and some people have more red or more prominent scars. And so a lot of the scarring is really an individual thing.

Monique Ramsey (15:10):
But I love the fact that you and nurse Christina and your team, your job is mostly in the OR, but then afterwards, I mean you see your patients very regularly, Christina, the nursing team sees them, and if things are starting to go in a direction you don't want, that's when you guys can make those adjustments and help maybe help that person's body do better.

Dr. Brahme (15:34):
Many of these patients, it has to be said that because the skin has lost a lot of elasticity and during the surgery we make people as tight as is safe, but still everything loosens up. There may be a need for some extra tightening, say at a year after surgery that when things have loosened up. And that's a very common thing. And I tell patients that in the consultation that there may need to be a secondary procedure to get the final look. And usually what we do is that if we start with the stomach, then we come back later and do maybe the breasts. And if the stomach needs to be tightened up a little bit more, that's a good time to do it.

Monique Ramsey (16:18):
At that point, you wouldn't be doing any muscle work, you'd just be tightening the skin.

Dr. Brahme (16:22):
Yeah, just tightening up skin.

Monique Ramsey (16:24):
You did drop the word drains earlier. Tell us about drains and how long do they stay in? Does it matter between breasts and body or face even? And what is the purpose of the drains?

Dr. Brahme (16:38):
Well, the purpose of the drains is to, as the name suggests, drain out fluid. And because we lift up the skin, there's a big space under the abdominal skin, and so we want to keep the fluid away from there so that it heals sort of like a sandwich. And the drains usually stay in, rarely we remove them earlier than a week, and rarely they stay in more than two weeks. So usually somewhere in the one to two week range. When we do the face, I also use drains and they come out the following day. For the arms, usually about three to five days. The breasts, I usually don't use drains at all. And nobody likes drains, but they're there for a purpose and we just got to live with them.

Monique Ramsey (17:26):
You just sort of deal with it. And if you're sleeping half the time in bed or watching movies, what's a little drain between friends?

Dr. Brahme (17:36):
There's sort of more of a hassle when you're out and walking, but actually on Amazon, you can get these little drain pouches for about 10 bucks. And so there are all kinds of little solutions that people find.

Monique Ramsey (17:53):
And I actually had a question about that. So what kinds of things besides pain management with a pill, what kinds of things do you do to help people in that first, let's say two weeks of recovery?

Dr. Brahme (18:06):
We have a lot of creams for the skin, arnica gel that we use for the bruises and obviously pain medication, anxiety, medications, if people need that, and also compressive garments, which really help with comfort management because when things are sort of loose and jiggling, it's much more uncomfortable. People feel safe having an external garment, and we have everybody wear those for at least six weeks, and some people come in at three months and they're still wearing them because they just feel more comfortable in them.

Monique Ramsey (18:46):
In terms of longevity for the surgery, you said you might have to make a small modification at some point, but let's say you had a lower body lift or a breast lift. Is that something that you have to have done over again in 10 years or 20 years or five years?

Dr. Brahme (19:02):
No, once you've reached your endpoint, unless there's some drastic change in your weight, if you should gain all the weight back, for example, yes, that's a problem, but actually I've never seen that happen. I've seen people put on a little weight or so, but I've never seen anybody go back to their former self.

Monique Ramsey (19:26):
Okay, now let's say it's a patient who's never had children very young, had lost a lot of weight, and then you get all lifted and tucked. Could they still have children afterwards?

Dr. Brahme (19:41):
Of course, yes. They can have children, and the body has a wonderful way of adjusting and stretching and so on. I've had patients who've had tummy tucks and had kids afterwards.

Monique Ramsey (19:55):
So I think the last question I really have is around cost. And does insurance ever cover this kind of surgery?

Dr. Brahme (20:04):
Sometimes if there is a medical necessity, insurance may cover it. It's very rare. Insurance really is getting more and more strict about all these, and we don't take insurance in our office. It's rare that I think I've done one, it's called panniculectomy, where you just remove that abdominal apron for a medical necessity. And that's one patient in 30 years. The cost, I don't deal with that. It can vary a lot. I would say something between probably 25 to $30,000, depending on what you do. I mean doing only the tummy will be less. Doing more combined procedures will be more. Our coordinators are genius at figuring this out. And they also deal with financing. So we have great financing for patients because it is a significant expense.

Monique Ramsey (21:05):
Right. It's like a car.

Dr. Brahme (21:08):
Yeah, it's like a small car, but one that lasts forever.

Monique Ramsey (21:12):
And you look fabulous all the time.

Dr. Brahme (21:14):
Yeah.

Monique Ramsey (21:16):
You don't have to worry about the 80,000 mile checkup. I think you mentioned financing, and it is something that, we just did a podcast the other week with Janelle who has tons of experience on patient financing, and it's very normal and people don't realize. And it's like you wouldn't think twice about getting financing for your car, but people don't realize you really can't have these things financed because it is a big surgery and you do want, I think, the sooner you do it, if it bothers you, the longer you can enjoy it.

Dr. Brahme (21:50):
Exactly.

Monique Ramsey (21:50):
You can amortize

Dr. Brahme (21:53):
Exactly.

Monique Ramsey (21:53):
In the girl math.

Dr. Brahme (21:54):
Amortize your happiness.

Monique Ramsey (21:55):
Well, why not?

Dr. Brahme (21:56):
The coordinators, when they talk to the patients before they come in for their consultation, they always give them sort of a ballpark estimate of what they think things are going to be, and they're usually pretty right. Usually there's not a lot of sticker shock when people come in.

Monique Ramsey (22:13):
Is there ever, in the OR, two of you two doctors, if the procedure so big? Do you ever have an assistant?

Dr. Brahme (22:21):
Yeah, we do. If we really are trying to get a lot done, say the patient lives elsewhere or something like that, and we would like to do as much as we can. We sometimes assist each other and that we can get more done in a shorter period of time

Monique Ramsey (22:40):
If that's needed. Now you brought up out of town, one last question. I know I already said it was the last question, but one last question. So if somebody is coming from out town, how long would you want them to stay here before they go home?

Dr. Brahme (22:53):
Well, it depends on what we do, but I would say to be safe, minimum of 10 days. Two weeks would be ideal, but a minimum of 10 days or they can have some arrangement maybe with their doctor back home to remove drains and things like that.

Monique Ramsey (23:12):
Okay. Are there any stories that you can think of that stand out to you in terms of that feeling afterwards?

Dr. Brahme (23:18):
Oh, I have great stories of patients who lost a lot of weight and met their childhood sweetheart and got married afterwards, and they're just so many stories. And people who went from a size 14 to a size two can do ballroom dancing, like I mentioned earlier. I have a patient who is, I think she's in her seventies, and she went from a size 12 to a size two, and she sent us pictures of her in her ballroom gown and just looks spectacular. So there are always some good, always great stories.

Monique Ramsey (24:01):
That's neat. Well, you sent it right at the beginning, this is the life-changing surgery.

Dr. Brahme (24:06):
It is.

Monique Ramsey (24:06):
Losing all that weight is life changing, but then being able to really enjoy it by taking off that extra skin, it's almost impossible to hide.

Dr. Brahme (24:15):
It's tailoring.

Monique Ramsey (24:16):
Yeah. Yeah. Well, that's something you're an expert at. I mean, you have so many happy patients with, well, with everything you do, honestly, between all your great facial work and then also all the kind of mommy makeovers and body lifting, it's really wonderful.

Dr. Brahme (24:38):
It's so nice to be a part of their journey. It's my greatest reward when they come in and just say, oh, it's been life-changing.

Monique Ramsey (24:47):
Yeah. Well, thank you Dr. Brahme for joining us today.

Dr. Brahme (24:51):
My pleasure.

Monique Ramsey (24:51):
And for the audience listening, you can look in our show notes for links to, we can send links to pod, other podcasts. I think we've talked with some patients who did lose a lot of weight and you can hear from them. And then also links to our before and after gallery and links for financing, pre-approvals, because why not if you're thinking about it. So thank you again everybody, and we will see you on the next one.

Dr. Brahme (25:18):
We'll see you. Bye-bye.

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