My Plastic Surgery Consultations (Part II)

See Part I for how I picked the surgeons I went to see for consultations.

My first consultation was with a surgeon that has experience with both facial surgery and Mommy Makeovers, but seems to emphasize the tummy tucks/Mommy makeovers more than the facial surgery.  Most of the reviews on Realself were from patients who either had a Mommy Makeover or a tummy tuck or breast work.  But, the facial reviews that did exist were good. And, he had a number of Before and After photos on his website for facial work and they looked good.  The photos were a little small, though, so I hoped he would have more photos in his office or would have larger copies.  Surgeons have to get permission from patients before putting them on their website or in photo books in the office. I had read that sometimes there were more photos in the office because patients would agree to that more readily.

When I went into his office the first thing that they asked me to do was to change into a robe, removing everything except my underpants.  The doctor came in and greeted me and asked me a little bit about what I was wanting to do.  I went through the stuff on my face from going from eyes to neck.

Here is a picture of me from last month.  Look especially at my eyes and the skin hanging on the sides of the eyes.

Face 4

To give a better idea of what I showed the surgeon, here are some pictures I took yesterday with no makeup on and my hair back.  So, this is absolutely me at my worst.   This one shows my overall face and you can really see the drooping eyes.  You can see some jowl sagging and how I have lost volume in my face as I lost weight:

Face 2

Contrast the above with my birthday picture from 2 years ago when I weighed about 30 pounds more than I weigh now. As you can see, I had the drooping eyes but had a lot more facial volume since I had a lot more fat in my face then.

Birthday1crop

One of my big concerns is the cholesterol deposits on my eyes.  I don’t currently have high cholesterol.  It was a mildly high for awhile, but people can develop xanthelasma even with normal blood cholesterol.  Here are a couple of good pictures showing these deposits:

Deposits Lower Lids

 

On the bottom picture you can see that the deposits extend to just above my cheek bones.  Once there, these deposits simply don’t go away.  They must be removed and you have to hope they don’t come back.  Mine have not gotten worse in a few years so I am hopeful they will not return once removed.

After my eyes, what I dislike the most is my neck.  This area has really got worse with weight loss.  The fat vanished but the loose turkey neck remains:

Neck Front Neck Left Neck Right

 

After I pointed out all of this out to the surgeon, he had me show him the rest of what bothered me.

I stood up in front of a mirror while he looked at me with the robe open.  He measured the droop of my breasts.  Then he looked at my abdomen.  He commented that most of what he was seeing was loose skin.  He felt that between removing that and repairing the abdominal muscle, I would see a big difference. I really sort of hate to post pictures of my abdomen, but to understand why I plan to do surgery I think it is important to see what I am dealing with (you will just have to imagine the droopy chest, though).

Note that I have a BMI of 24.5 as of last Saturday.  I weigh 142.8 pounds with the top of my goal range at 146 pounds.  So, I am normal weight. Back in the early 90s when I weighed what I weighed now, I didn’t have the loose skin that I have now.  Back then, at my current weight, I wore a couple of sizes smaller than I weigh now and my waistline was about 5 full inches smaller than my current waist.  Of course, back then I started at 168 pounds as my then high weight.  This time I started at 207.4 pounds and I had a pregnancy since then as well.

Tummy Front Tummy Right Tummy Left Tummy Leaning Tummy Hang

 

About the best I can say about the abdomen is….you should have seen it when I weighed 65 more pounds than I weigh now!  It is now a more deflated version of what it was then.  Oh, one of the things I discussed with him is that surgery can remove loose skin and can remove subcutaneous fat.  It doesn’t remove visceral fat which is the fat around your internal organs.  He said I mostly had loose skin with some subcutaneous fat. I told him that I had read on Realself that one way to determine if you have visceral fat is to lay down on your back.  If your abdomen lays flat, then you have mostly loose skin and subcutaneous fat.  If your abdomen protrudes higher than your rib cage, then you have visceral fat and surgery can’t remove that fat. He said that was true.  I said that I had laid down and my abdomen was flat when I did that.  He commented that I should have a good result from surgery.

After showing him my chest and abdomen, he had me get dressed and then he came back in to talk to me.  For my face, he recommended a temporal browlift (basically just lifting the brows at the temple area), a SMAS facelift (to pull up the underlying muscle and the sagging skin), and a necklift.  He would also do an upper and lower blepharoplasty for my eyelids to basically remove the loose skin. We also talked about the cholesterol deposits.  He didn’t want to excise them during the eyelid surgery as he was concerned about healing.  He had in mind that I would see a dermatologist either 3 months before the facial surgery or 3 months later.  I knew from past research that sometimes people remove (or attempt to remove) xanthelasma through either laser or chemical peel.  Other times, the deposits are excised through surgery.  I knew there were pros and cons for all the solutions and I knew that xanthelasma sometimes return.

For the body, he recommended a tummy tuck coupled with a breast lift.  The breast lift would involve an anchor type incision and would result in my losing one-half to a cup in size due to removal of the lots of loose skin.  Some people get a breast augmentation when they have a lift, but he said he didn’t think I should do that.  That was totally fine as the very last thing I want is an augmentation.

For all the procedures he described what he would do and it was all very clear (but, then, I had been researching this stuff for years).

And, then I started with my questions.  I had a ton of them, but will just highlight a few. I asked him if he thought I would need muscle repair on the abdomen.  He felt that I would need it and talked about how repairing the underlying muscle laxity would help to shape my abdomen.  He would also do some liposuction to the flanks to help with shaping the waist.  I already knew that having a tummy tuck is not a substitute for weight loss.  The amount of weight lost from the excision of the skin and some fat is relatively small.  This will make a big difference in how my clothes fit and how my abdomen looks but it want make a big difference in terms of weight.

I had a discussion with him as to whether it was safer to do the tummy tuck and breast lift in a combined procedure or whether it was safer to do them separately.  We talked about the risk of the combined procedure which is the greater length of time in surgery while the risk of the separate procedures is that of having to be under general anesthesia twice.  He thought it was less risky to combine the two procedures.

I talked to him about the potential complications of the procedures and what complications he sees most often. I knew that especially for the tummy tuck/Mommy Makeover that one of the biggest risks is that of blood clots in the legs which can result in a pulmonary embolism.  I had researched this in advance and asked him about what he does to lessen that risk.  I did have a strong feeling in the discussion that he was very aware of safety concerns and didn’t want to do anything that was risky.

I asked him if he thought I needed anything to increase volume in the face or to do any surface treatment.  He felt my facial volume was OK and felt we could look at the facial skin surface after surgery to determine if anything more needed to be done.

I talked to him quite a bit about how often he did facial surgery versus how often he did tummy tucks and breast work.  He said he did do facial work every week but did more body surgeries.  I felt he did an acceptable number of each, but I felt he focused more on the body countering.  Later his assistant said that he basically limits his practice to body contouring (mostly after weight loss or pregnancy) and the type of facial surgery I have.  He doesn’t do nose surgeries, for example.

We talked some about surgery and how he would want me to stay overnight at the hospital after surgery.  I was fine with that and it was one reason I had wanted to consult with him.  We also talked some about the recovery period and he wanted at least 3 months between the facial surgery and the Mommy Makeover.  He also wanted 3 months between the cholesterol deposits being removed and the facial surgery.  He said it didn’t matter what order I did them in. I was a little surprised by that as I had researched this and had read the time between surgery that was needed was more like 6 weeks. But, I also knew every situation is different.

After I finished talking to him, his assistant gave me the quote for surgery.   All of the facial work except the cholesterol deposits would be done in one surgery.  I also had asked him about ear lobe repair.  My ears were pierced too low when I was 13 years old.  They had almost torn through entirely over the years.  I am at a point now where I can only wear very light earrings.  If I wear anything else, my ear turns under as soon as I put the earrings on and it is clear that it won’t take much for the holes to tear through.  If I am doing all this facial stuff, I want to be able to wear my earrings later!  I was given a quote for the ear lobe repair and it was the same amount whether he did it as an office procedure or if he did it as part of the other facial work.  I had a choice of two places I could do the surgery.  One was closer to my home, but was more expensive than the hospital that was a little farther away.  I was OK driving a little farther to save quite a bit of money. I didn’t get a quote for the excision of the cholesterol deposits because he wanted me to see a dermatologist for that.

I also got a quote for Exparel. I had learned about Exparel on Realself. This is a local anesthetic that is injected at the time of surgery at the surgical site and numbs that area.  This is on the tummy tuck surgery, not the facial surgery.  A number of people on Realself have reported that it really reduces the pain for about 3 days after surgery and greatly reduces the need for narcotic pain relief.  Also, with less pain, you can feel more like moving around and you want to do that after surgery to reduce the chance of blood costs.  I asked the doctor about the Exparel and he had a high opinion of it.  The hospital does charge $350 extra for it, but I knew I would definitely want it.

When I had been waiting to see the surgeon, I had flipped through his books of Before and After photos.  There had only been one facial photo.  There were more of them on the website, but I was disappointed there weren’t more in the office.  The photos on the website looked OK, but they were sort of small so I was wanting to see more of them in the books. The assistant said it is more difficult to get permission to show facial photos and that everything they had was on the website.

I left the appointment with a largely favorable opinion.  I had no concerns about how he would do the Mommy Makeover at all.   I wasn’t entirely thrilled with how he wanted to handle the cholesterol deposits, but I was reserving judgment until I went to the next consultation.  One of the things I was really curious about was how similar the recommendations of the other surgeon would be.  Sometimes I’ve seen people come onto Realself and they got wildly different recommendations from different surgeons.

Two days later I went to the next consultation.  The process was similar.  One difference was that this surgeon came in and briefly discussed what I was concerned about before I changed clothes.  Then I changed and he looked at everything and then we talked while I was still in my robe.

Overall, the recommendations of both surgeons were very similar.  The primary difference was in the handling of the cholesterol deposits.  This surgeon recommended excision of the deposits.  He felt that he could do most of the excision during the blepharoplasty (eyelid surgery).  He had the same concern as the other surgeon about wanting to be careful about healing.  But, he felt that as part of the doing the upper and lower eyelids he could remove most of the deposits.  He also felt that he could remove the rest of them 4 to 6 weeks after surgery.  He commented that he could do laser, but that he felt excision was more effective.  I had done quite a bit of reading about how to handle these deposits and felt that excision was the better approach and more likely to be of lasting benefit.  He didn’t think that excising the deposits before the blepharoplasty made much sense because he thought that most of the excising would done during the surgery so it made more sense to excise what was left over later.  This was the biggest area where I felt he differed from the other surgeon and I preferred his approach.

He initially didn’t suggest a temporal browlift and I asked him about that.  We discussed the pros and cons of doing it and I ultimately was inclined to do it. He also thought that while I didn’t need much facial volume, that I would benefit from some fat transfer.  He would use some of the fat from my neck to do the fat transfer.  From my research, I know that it is best to be cautious on fat transfer.  It is permanent (unlike a filler) so I would rather put in too little than too much.

As far as the tummy tuck/breast lift were concerned, I felt that I would be comfortable with either surgeon.  Like with the other surgeon, I asked him a lot of questions.  I asked about blood clots and what he would do to avoid them, we discussed general anesthesia and whether it was better to do the tummy tuck and breast lift combined or separately.  He also felt it was better to combine them.

I discussed with him how often he did these types of surgery.  I knew he had originally trained as an otolaryngologist and then had trained in plastic surgery.  Despite this, he said he did about 50% facial work versus 50% body.  My sense, though, was that he did more facial work than the other surgeon.  And, the other surgeon did more tummy tucks.  The second surgeon said that I would need a minimum of 6 weeks to recover between surgeries while the first surgeon had said 3 months.  I had researched this previously and had more commonly seen the 6 weeks.  I am not sure it makes more difference as I won’t schedule the second surgery until after the first one and by then it will be summer when it is harder to schedule surgery.  It will probably be close to 3 months between surgeries in any event.

He was very patient at answering my questions and seemed to have all the time in the world.  I felt that this consultation was a bit more thorough than the other consultation, particularly on the facial surgery.  One difference was that this consultation cost me $75 (the fee would be applied to surgery if I ended up using him), while the first consultation was complimentary.  I don’t know if that was a factor or not.  I also liked that he had a display in the examining room where he showed large photographs of people he had done surgery on where he used those photos to illustrate what he would do in my case.  I had seen most of these photos on his website, but it was helpful to see them blown up and to have him explain what he did and how he would apply that to me.

After I finished with the surgeon, I met with his coordinator to discuss the cost of surgery and to answer any other questions about financial stuff and scheduling.  Before he left, the surgeon emphasized that I could come back and see him again if I had more questions.

When I met with the coordinator I found that the surgeon’s fee was very similar between the two surgeons.  This one also gave a discount if I didn’t use Care Credit. The big difference though, was that the facility fee was much higher for the hospital where this surgeon does his surgery.  And, the hospital location is about an hour and a half away from our house.

What I found from the two surgeons is that there are a lot of different costs that go into surgery.  The main ones are:

  1.  Surgeon’s fee — This was similar between the two surgeons, with each giving a discount if you weren’t using Care Credit.
  2. Operating Room fee – This is paid directly to the hospital and varies depending on the facility and the expected length of surgery.
  3. Anesthesia – This is also paid to the hospital and varies depending on the facility and the expected length of surgery. For both surgeons, the additional cost for Exparel was $350 (both surgeons favored using the Exparel).
  4. Room – Both surgeons for both surgeries wanted me to stay overnight and I was totally OK with that.

So, the last 3 charges were a lot more for the hospital the second surgeon uses.  For the facial surgery, it was about $3600 more and for the Mommy Makeover it was about $4300 more.  Those are big numbers.  On the other hand, within reason, I don’t think that I want to choose a surgeon based upon cost.

If I had two surgeons and they completely tied and it was a coin flip between them, then I could see deciding it based upon cost.  And, of course, if something was so expensive that it was just beyond what I could pay in terms of cost then I would eliminate that surgeon.  But, this is not the type of thing where I wanted to go with the cheapest surgeon. In this case, the difference was primarily in the costs due to the hospital.  I decided that I would make my decision based upon which surgeon I preferred.  The initial quote for the second didn’t include the browlift or the ear lobe repair and I called and got a corrected quote issued. At the same time, I didn’t have a cost for excising the cholesterol deposits from the first surgeon because he wanted me to see a dermatologist for that.  For the purposes of comparison, I assumed that the cost for that was the same with both surgeons.  Also, the second surgeon was less expensive on his fee for the ear lobe repair.

It was a difficult decision.  I liked both surgeons.  Their recommendations were very similar.  I thought that both of them would overall do well.  I decided that for the facial surgery, I would go forward with it and would choose the second surgeon.  There were several reasons.  First, I felt that he had a bit more focus on facial work than the first surgeon.  Second, removal of the cholesterol deposits is really important to me.  I know that there is a chance that they can return in any event.  But, I have done a lot of research on this and I liked the approach of the second surgeon better.  This was the major difference I saw between them in what they wanted to do and the second surgeon had the approach that I preferred. Third, I thought his consultation was more thorough with regard to the facial surgery.  He spent more time examining my face and considering options and did more explanation.

So, I went ahead and booked the facial surgery for May 9th!  I will go for a pre-op appointment on April 26th and there will also be some lab work that has to be done.  I am really excited to be getting this done.  I really debated which procedure to do first.  On the one hand, I really want to get the body contouring done.  The tummy tuck, especially, will make a big difference to me in terms of how clothes fit.  My husband said he thought that the tummy tuck/breast lift would have the longest lasting effect on my body.  At the same time, psychologically, the face is really bothering me a lot.  The eyelids and the neck and those cholesterol deposits really, really, really bother me.  I hate having pictures taken of me.  The first picture in this post was taken when we took my mother out for her 92nd birthday.  I posted pictures of everyone else on Facebook.  I didn’t post the picture of me because I hated it.  So, I definitely like getting the face done. But, I also really want to get the Mommy Makeover done as well.

Ultimately, I decided to do the face first for 2 reasons.  First, I think the recovery from the facial work is easier than the recovery from the Mommy Makeover.  The tummy tuck is a difficult recovery from everything I have read.  I think that if I do the face first I will be able to do the Mommy Makeover sooner than I could do the face after the Mommy Makeover.  Second, I will likely have to complete excisions of the cholesterol deposits 4 to 6 weeks after the facial surgery.  A good time to do that is while I am still waiting to do the Mommy Makeover.  If I do the Mommy Makeover first, then I have to wait to do the facial surgery, and then still more waiting to finish the excisions.  By doing the facial surgery first, I probably end up completing everything sooner than if I do the Mommy Makeover first.

I have not yet decided which surgeon I will use for the Mommy Makeover.  I think I could use either one of them.  This is a much closer decision than the facial surgery.  So, I’ve decided not to decide until after I do the facial surgery.  I have a few more questions I want to ask the second surgeon about what he would do and I will just reserve that decision until after I do the facial stuff.  So, we’ll see.

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