For Charming (a.k.a. the iconoclast)

Not sure when or even where Charming asked this question, but I cut it and pasted it, then closed out the windows.

Anyway, she asked about all the medical and psyche clearance needed for WLS 

 . . but to get 100" of incisions and 50" of suturing, I just had to get bloodwork and clearance from my regular physician?

It seems to me that plastics/reconstructive work are areas where patients are likelier to be resolving personal and emotional issues to some extent . . . Why does this remain largely an issue in the arena of the surgeon's general discretion?

Well it's a great point, and I will say that even at our professional meetings not enough is said about WLS patients' mental and emotional health. 

The short answer is that INS has no financial stake in most PS, so they "don't care" about selecting the right patient. If you're unhappy, it doesn't directly cost them. But if you fail WLS, then the obesity does cost them.  Sad, but you all already know it's all about the $$$ with them.

Because overeating and obesity may just be symptoms of other issues (that WL surgery does not necessarily correct) many WLS patients still lug around a lot of "baggage." Like

Bad relationship(s)
Cross addictions
Poor body image
The "usual stuff"  like anxiety, depression, etc

For this reason, I meet with everybody an hour or so and just find out "where they are."  If they come from a local bariatric surgeon, I may already have heard about them.  Their bariatric coordinator or support group leader may have spoken to me about them.  If it's a reputable surgeon, then all the better.  The "slash and dash" guys typically have poorly selected, poorly prepared, poorly followed patients who often are doing...poorly !

Its also important to be sure to examine their support system.  Some of the red flags I look for are the "angry spouse,"  "jealous husband,"  "resentful friends/family", "overprotective parents" or "saboteur" who may negatively influence the patient's recovery.  I will request face-time with these individuals before sugery too...helps me lay some ground rules, identify problems, and address issues.  Really helps when the family is just scared or worried.

A major issue (because it's so common) is the failure of the patient to see in the mirror what we all see in terms of result.  A lot goes into this phenomena, but basically patients will be kind of giddy the first week after surgery or so, then get very morose around 3 months.  They feel the surgery wasn't worth it, or focus on the negatives.

Pain meds, sleep cycle disruption, lowered activity level, weight gain, needing to eat more, and a host of other things contribute to this depression but it usually goes deeper.  I think the patients more deeply dissatisfied with their body image before PS have the hardest time adjusting after PS.  Those whose childhood development was affected by obesity are often the worse.  MAYbe they never saw a "normal" image in the mirror and don't know what to expect.

About all I can do here is explain ahead of time they may have some adjustment issues after PS.  That recovery after PS and getting "good" with the mirror (and losing the "scale mentality") is a process that can take time.  That spouse, family, and friends may get frustrated and tired of telling them they look great even thoug they don't feel great.

I've found that getting out the "before and afters" 3-6 months down the road really helps show how far they're come too.

Anyway, Mary Jo Rapini and I are working on an interview to be posted on my website about these and other issues.

Hopefully she will be a bit smarter about it than I !


 

I was about to write, “You know, Dr. LoMonaco – you are so extremely good at explaining things well – Honestly, you should write a book about this."  And then I found out – you did!!!

I am so NOT an iconoclast – but it’s nice to be called one, anyway! 

Here’s my concern:  There are the patients undergoing reconstructive procedures, and that’s ONE ball of wax.  And then there are the primarily cosmetic patients, and that’s a DIFFERENT ball of wax – but in the patients’ minds, WE  all view it the same way.  We all feel we need the procedure to make us whole and well – and we rely on the judgment of someone else to know when surgical treatment can bring that about.  That is why I wish there were the equivalent of “Centers for Excellence" in the world of plastic surgery (and perhaps there is, but I am clueless.)

 

As you point out, conflict-of-interest is often inherent in medical care.  The patient is a person in need of SOMETHING to make him or her whole and well.  The physician and insurance companies are there to help provide a measure of care, but the patient is also a revenue source – This will always be a problem (and I shudder to think what this could be like under federally managed care, when some parties stand to make a great deal of money by withholding care instead of by providing it – then a matter of government policy, and not just individual insurance companies – another long post for someone, I’m sure).

Looking back on my consultations, more and more I realize that while I was evaluating the surgeons, of course they were evaluating my suitability as a patient, as well.  What you wrote, above, illustrates this – You are checking for the patient’s social and emotional considerations, the supportive relationships, and expectations.  Patients check references – it had not sunk into my mind that of course doctors in a way are also checking patient references, too!  But of course – My WLS surgeon recommended my plastics surgeon, and that process works in reverse! 

The thing is, that as you wrote:  Because overeating and obesity may just be symptoms of other issues (that WL surgery does not necessarily correct) many WLS patients still lug around a lot of "baggage." Like

Bad relationship(s)
Cross addictions
Poor body image
The "usual stuff"  like anxiety, depression, etc

. . . all of these things are possible and likely for people pursuing cosmetic and reconstructive surgery, too.  Holy cow!  I live in Plastic Surgery Central!!!  This town is chock-a-block with borderline personalities suffering from confused and distorted images of themselves, all in desperate need of cosmetic reformation into something ELSE.  And there is no standard way of assessing this – neither is there any surgical standard of establishing that some people really should not have procedures performed!!! 

I’m saying this like you’re unaware – obviously, you ARE aware – but ole golly moley – it’s like the wild west in terms of ethical standards for plastic surgeons, isn’t it?  In California, at least, it seems doctors are free to perform any procedure they like no matter what training they have, or are missing – and they are also free to treat any patient, whether or not it is necessary or appropriate.

 

Of course, for me this leads into the issue of people who opt for procedures-from-afar, including abroad – and the only contact they’ve had, the whole consultation, consists of phone calls and exchanged emails and photos – augmented by a potential patient’s willingness to pay.  Are there many such patients who get all the way to Antigua, or Costa Rica, or India, or wherever . . . only to find that the surgeons says, “I realize that you are not a good candidate for this procedure because of social and emotional issues, and I’m not operating – sorry" --???\

Thank you for letting me vent on this –

By the way, my surgeon gave me photos of my “before" and “after" – and whenever I’m second guessing my choice, I take a peek.  My reaction is always WOW!!!  There’s no perspective like the truth of the camera!!!

Charming -
You make some excellent points here.  I think because of where we live, we have seen so much in terms of cosmetic surgery.  How often are our mailboxes flooded with ads from the local cosmetic surgeon promising everything?  And the billboards! Oh man, we live in the land of the perfect, and that can so cloud our reality when we still think of ourselves as the fat girl. 

I know that my reconstructive surgeries (and I really chose to see them as that and not cosmetic) have been most healing to my emotions and psyche.  i finally feel like I fit in, and that I am "normal" in appearance.  They have helped detatch my mind from thinking of myself as heavy.  I don't live in the wrinkles and rolls of tissue anymore and I can feel free.  It can be easy to cross that line and start picking at the other things that I might not like about how I look, but then I've crossed over into self hate.  There is a line there, and for some, it can be might thin. 

Because we don't always think straight on these things, we have to work with someone - a support person, or in many cases a professional counselor who can help us sort this out and put it into a perspective that makes us see the difference.  I too, get out those before and after pictures and while there are things that are far from perfect, I am so happy with my results.  I know that the day I posted my 3 day post op legs, which I was THRILLED with, someone sent me a message asking how I could be so happy with the result since my knees and lower thighs still looked so fat.  I was crushed.  I removed them from my friend list, but had they had my perspective of how far I'd come, and truly what my legs looked like before, and the fact that I'll never have Barbie legs, maybe they wouldn't have said that.  Others will always judge us, and we will judge ourselves, but at some point, we have to become comfortable with the person who lives in our skin and that will help us become more confident and comfortable with how our skin looks.  IYKWIM.

I do appreciate your challening and thought provoking posts.  I think we've seen what can happen in the land of the beautiful.

Thank you so much for taking the time to post this, Doctor.  It is really an invaluable service for the clients to have such an insight to the evalution process.

Very insightful information!  My emotions have been running amok the last few weeks and I was actually thinking today that I should call my counselor on Monday who I was seeing pre-RNY (to help deal with emotional eating issues) and maybe go in and have a chat with her. 

I'm not typically a very patient person and I found that when my husband took my 4 week post-op pics this week, I felt a little down that I didn't see much difference over the last two weeks.  In fact I told him I think I looked better in my 2 week pics, than I do now.  I know in my head that I'm still swollen and that it's going to be a few months before I see more progress, but the question pops in my once in a while wondering if I'm where I should be as far as results and what normal looks like .  

I am one of those folks who have had weight issues all my life - even when I was a teen and a size 10, my sister was a size 0-2, so I was the "big" one of us kids.  I try to think back on when I looked in a mirror at that size and thought I was normal.  I honestly don't remember ever actually really "seeing" myself in a mirror. 

I can see real progress in the fact that the mudslide on my abdomen is gone and now it's smooth and I have (and can actually see for the first time in a long time) that I have a belly button.  But now I'm constantly looking in the mirror to see if the swelling's gone down, or if the pooch is bigger this afternoon than it was this morning.  I don't know what "normal" looks like so have no clue what to expect.  I do know my surgeon is pleased with the results so far and he's been through a whole lot more of these procedures than I have, so I'm sure I'm doing just fine progress-wise.  I just need to learn some patience and give my body a chance to get wherever it's going to end up.

I'm thinking the counselor might not be such a bad idea just in case I'm still feeling this way in a couple months, so I can be working towards learning how to deal with "normal" and what it is and what it's not.

Thanks Dr. L - I appreciated reading your insight. 

Something that we were not prepared for was my husbands feelings regarding the plastic surgery.  He is extremely supportive and wanted me to have the skin removed since it was causing so many issues.  We have been married for 27 1/2 years and it was just a month before our 26th anniversary that I had my LBL.  I was heavy when we married - had been heavy my entire life.  He had gotten used to the changes over the 1 1/2 years it took to lose the weight, including cutting my long hair as it had fallen out and my now more than ever sharpei body.  What was so hard for him was that not only didn't I look like the same person anymore, but my body no longer felt the same.  He would roll over in bed and put his arm around me, and pull away - it was so different to have no rolls and no fat that he felt that he was with someone else.  It took us a few months to deal with that and for him to adjust to the new me.  No one had ever mentioned that in preparing for plastics.  While he loves my new shape and all that, he fell in love with ME and never once put me down for my size/weight. He has always been so supportive, but it was something that he just didn't expect.  I didn't come in the package he was now seeing and feeling when we snuggled.  I often speak at classes for patients preparing for WLS, and this is one of the things that I bring up.  Even with the most supportive spouse, they can have issues with this stuff that takes time to sort out.

There is so much to consider in terms of body image and our feelings.  I still have my heart beat hard when walking into a movie theater and thinking that I won't fit in a seat, and I once argued with my husband that we could not go to an Angels baseball game because I could not fit in the seat.  I was wearing my size 8 jeans and he just laughed at me!  It does take a bit for our mind to catch up to our bodies. I will get a glimpse of myself in a mirror and have no idea who the skinny woman is.  It does take time, and after plastics there is another adjustment.  I can see flaws, but I really try and see how far I've come.  I still have my "wish list" of things I would like to fix - knees and calves at the top of that list now that my arms and flanks have been addressed.  I struggle with "neighborhood syndrome" from time to time - this looks great now, but now this looks REALLY bad and we have to do something about that.  It can be a never ending obsession, or we can look at where we've come from, and be happy about where we are and the progress we've made.

Thanks for sharing that about your husbands feelings.  My husband has some issues but they are a bit different.  He has been feeling really guilty lately that he thinks I am so much prettier now than before.  He says he loved me so much before and thought I was so beautiful before.  It hurts him to admit that he thinks I am more beautiful now, and I understand where he is coming from but I don't know how to ease his pain.

I just tell him that I love that he thinks I am more beautiful now. I didn't go through weight loss surgery, losing 150 pounds and plastic surgery for him to NOT think I am more beautiful.

Kristi -

My husband had some similar issues as well and was having a hard time admitting that even though he loved me and was attracted to me before, he really liked my new shape and body.  I spent quite a bit of time thanking him for the support and for the fact that he always loved me and encouraged me.  I think that letting him know that I could understand, and that I was happy that he was enjoying the new me and had always been so loving and faithful before helped.  Keep reassuring him.

All of these things are issues that no one wants to address or doesn't think are needed, but they are issues.  It is awkward to bring up when I speak at classes, but I've found that it is something that is so needed in preparing people for the changes that they are going to go through.  I also find it a bit hard to answer the questions about unwanted attention from people that you don't want to receive attention from.  I now avoid this one car wash because an employee from there feels the need to ask me out or just ask if I want to go back to his place.  I don't have a clue why he would say that to me - I'm not dressed inappropriately, and I'm not showing attention to him.  But those are things I bring up too.  It's all part of the section on stuff no one ever told me about WLS.

I do have men treat me very differently now.  When I am alone or with friends I find it very flattering, nothing has gotten out of hand so far thankfully...

However when I am with my daughter it is a bit of a problem.  She has actually gotten upset at me when men show me attention.  We went out to dinner for example and a man asked me out and she said, If you didn't look like that, this wouldn't happen.  She was visibly angry at me and I had to explain to her that it wasn't my fault.

If a man tries to get a door for me, she will say to them, no thanks I can get this, and gives them an attitude, which I don't want to happen either.  She has gotten better as I have explained to her that people are just being nice and nothing they say or do will make me ever want to leave her father.

OK Charming, I think you DO undermine "accepted" ideas all the time...like "PS as a cure-all" and "mesage boards a s a source of physician referral."  Admit it !

But seriously....

At the very least, I hope this kind of discussion can alleviate the anxiety many people have right after surgery....there is even a post about this below I think !

Individuals who feel they are "going nuts" right after surgery are usually suffering from the effects of the meds (narcotics and narcotic withdrawal especially have powerful emotional effects), sleep cycle disruption, pain, and the severely altered daily routine...inactivity being a major issue here !

Looking at the bigger picture, perhaps we can move forward to gently uproot the idea that plastic surgery is an psychological cure-all.  No doubt, it's a beneficial and even essential part of many people's journey, but it's not  a panacea.

And thanks for allowing me to share in ALL of your remarkable journeys.