Should I go for an extended tummy tuck or fleur-de-lis? Bariatric surgery done 13 years ago (photos)

Question

I’m a bit confused as to which procedure to go for. Currently, I am 77 kg, and hoping to lose more weight by May. My highest was 124 kg before bariatric surgery in 2009. I’m 162.5 cm. Could I get away with an extended TT and 360 instead of F-D-L TT?

J. Timothy Katzen, MD, FACS · Answer

Thank you for your question regarding if you need an extended tummy tuck or fleur-de-lis. By examining your photos, it looks like you might benefit from a 360 circumferential lower body lift. This would address your buttocks, hips, abdomen, and mons region. If your buttocks don’t bother you, maybe consider an extended tummy tuck with vertical torsoplasty to address back fat and give you an hourglass figure. An essential part of your tummy tuck will be the muscle plication (which will bring your abdomen in by 4-6 inches). Muscle plication should be included in your tummy tuck.

Thank you for your question regarding if you need an extended tummy tuck or fleur-de-lis. I wish you the best of luck.

Thank you for your question regarding if you need an extended tummy tuck or fleur-de-lis. I wish you the best of luck.

Daniel Barrett, MD · Answer

Dear Naynay899,
it is hard to tell for sure without an examination. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Cagil Meric Erenoglu, MD · Answer

Hi, Naynay899! Thank you for your question and photos.
Regarding your photos, you have skin excess in both horizontal and vertical vectors.
Having an extended TT will help with horizontal skin excess, but will not help with vertical excess, which will be bothering you especially in sitting position. 
On the other hand, an FDL will help you better with more skin excision, better circulation of the flaps, and a narrower waist. The disadvantage is the vertical scar, but the gain is much more.
So my recommendation is a circumferential (360 degree) tummy tuck plus a vertical skin excision

Peter Andolina, DO · Answer

Based on your photos and my experience, I think you would benefit more from a Fleur-de-lis abdominoplasty. FDL tummy tucks really help to take up vertical slack in the loose skin that you cant get just with an extended tummy tuck.

Lourdes Rodriguez, MD · Answer

Hello, thank you for your question and pictures.

After evaluating your case you seem to be a great candidate for a tummy tuck to remove the skin excess on the abdomen combined with 360 liposuctions to reshape your body, The BMI need to be under 33 for surgery. By combining these procedures, we can achieve good results.

Make sure to approach to a certified surgeon to help you clear all your doubts.

Best wishes!

Connie Hiers, MD, FACS · Answer

Congratulations on your weight loss! You will have a tighter flatter upper abdomen with the fleur-de-lis than with the extended tuck.  However, you should still get good results with the extended tuck.  Lose all the weight you want to prior to surgery.

Camille Cash, MD · Answer

Congratulations on your weight loss!  It is best to get to your goal weight before considering surgery.  It appears you have excess skin on the upper portion of the abdomen.  This will be best addressed by FDL.  If you choose to have an extended tuck you will definitely have improvement, but you may be left with loose skin on the upper portion of the abdomen.  I've included a video about plastic surgery after major weight loss that I hope you find helpful.

Mats Hagstrom, MD (license on probation) · Answer

When individuals lose substantial amounts of wait they often develop skin laxity. Skin laxity is often you need directional meaning that it’s loose in both the horizontal and vertical direction. A traditional Tammy tuck including an extended or wraparound tummy tuck will only address skin laxity in a vertical direction. sometimes horizontal skin laxity can be distributed evenly around the torso avoiding the vertical scar of the fleur-de-lis pattern tummy tuck. For some individuals the best option is a both extended tummy tuck with a fleur-de-lis incision.
It varies from patient to patient and also varies substantially from surgeon to surgeon based on their personal opinion, training, experience and philosophy.
Personally I try to avoid the vertical scar when possible but it’s better to have a vertical scar then to look like you still need a tummy tuck.
I recommend having multiple in person consultations with local board-certified plastic surgeons in your community to get each providers opinion.
When discussing extended tummy tucks it needs to be very clear exactly how far the scars will go and specifically if the surgeon is going to turn you in the operating room.
By definition an extended tummy tuck reaches further then what can be reached with a patient lying on their back. in other words an extended tummy tuck requires the patient removed during surgery and put in a prone or face down position.
It’s possible the procedure can also be done with people laying on their side but generally speaking and extended or wraparound tummy tuck requires turning the patient.
Turning patient during general anesthesia is labor-intensive complex and not always popular with anesthesiologist or operating room staff. it is however necessary to do some procedures correctly.
There should be no ambiguity about the extent of a tummy tuck nor if the surgeon is going to turn you during surgery if you are contemplating an extended procedure. most people with significant weight loss will have a lot of skin laxity on the backside and benefit from an extended procedure whether or not they had the vertical incision. Some providers may be apprehensive of doing both and extended and fleur-de-lis at the same time and their opinion may be justified.
Ask providers to open up their portfolio and show you their entire collection of previous tummy tucks done and similar patients with similar degrees laxity.
Ask them to show you examples of both extended tummy tucks and fleur-de-lis patterns on patient with similar amounts of skin laxity so you can see firsthand what the results look like.
There’s no point in seeing results of patients who have significantly different body characteristics to your own. For reference an experienced surgeon should have no difficulty showing you at least 50 set a before and after pictures of commonly performed procedures like a tummy tuck. Highly experienced surgeons will have hundreds or even thousands of before and after pictures for these common procedures. The extended tummy tuck or fleur-de-lis are not as common as a standard full tummy tuck. These type of procedures may represent 10% or less of the tummy tucks done by a typical plastic surgeon.
There are plastic surgeons who specialize or perform more massive weight loss surgery than others.
Sometimes asking weight loss surgeons such as those who perform bariatric surgery for references of plastic surgeons who do go to work with weight loss patients after a successful weight loss.
I suggest you start the process by scheduling five in person consultations with local board-certified plastic surgeons in your community.
Take notes during the consultation in regards to how thorough each provider is as well as the quantity and quality of the before and after pictures that they showed you.
Don’t be in a hurry to schedule surgery I’d rather take your time and when in doubt slow down and schedule more consultations.
This is a big procedure and you need to be physically and emotionally prepared for it.
An argument can be made at massive weight loss patient may or may not benefit from muscle tightening as part of the procedure.
A lot has to do with each patients history of pregnancies and a determination if significant muscle separation is present or not.
Aggressive muscle tightening makes the mismatch between the size of your muscular skeletal torso and your skin envelope even greater.
Muscle tightening adds significant intensity to the recovery and if not indicated it’s nice to skip the muscle tightening part of the procedure.
If however someone has significant muscle tightening the not addressing this could also limit how flat abdominal wall will be after the procedure.
Most individuals have lost as much weight as you have or not looking for perfection but just want to get control over the excess skin. Having a perfectly flat abdomen is not necessarily one of their goals and having a recovery that’s far more gentle and easier may be a very reasonable compromise.
Muscle tightening is the part of a tummy tuck that causes the greatest intensity and discomfort during recovery. The pain from muscle tightening is temporary and does eventually subside.
I’m not suggesting people should or should not have muscle tightening as part of the procedure but I do think it is something that should be discussed and considered.
In your case do you have enough skin redundancy that it is possible that medical insurance may pay for part of the procedure.
Medical insurance companies never pay for a tummy tuck.
A tummy talk is always considered a cosmetic procedure.
What insurance companies sometimes cover is a procedure called a panniculectomy. A pannus is the medical term for the dependent or hanging skin of your lower abdomen. If this is causing skin rashes or fungal infections that cannot be treated medically some insurance companies will pay to have that excess skin removed.
Simply removing the excess lower hanging skin that is causing skin problems is not a tummy tuck. A panniculectomy is one aspect of a tummy tuck. The rest of the time attack which includes separating the skin and fat layer from your muscle layer up to your ribs and repositioning the belly button is considered cosmetic.
If you can get medical insurance to cover a panniculectomy and pay for the cosmetic part of the procedure you could potentially save a significant amount of money on facility fees, anesthesia fees and especially the ability to spend a night in the hospital or surgical facility which would be a major advantage compared to recovering the first night at home. 
To get medical insurance to cover a panic you like to me requires working with plastic surgeons who are willing to work with medical insurance companies and are willing to work with you to get authorization.
I panniculectomy is often denied by medical insurance companies when first requested.
It often Hass to be appealed and eventually go to manual review at which point you’ll need a plastic surgeon to argue in your favor to get the insurance company to cover it.
It does not always get covered but it can for patient to meet the criteria outlined in your insurance policy regarding indications for a panniculectomy.
It’s definitely worthwhile discussing with plastic surgeons during consultations.
Some providers may be willing to work with you and try to get authorization. It is also reasonable for them to charge a cash price for the cosmetic aspect that differentiates a tummy tuck from a panniculectomy.
Other plastic surgeons may simply tell you that they don’t work with medical insurance companies and they’re not willing to do the authorization. some may also tell you that it’s not a covered procedure etc. etc.
Look for plastic surgeons who serve as patient advocate and are looking to put your needs first.
Like I mentioned earlier it helps to have a few consultations so start scheduling those and see what individuals have to say.
I think you’ll be glad when you get all that extra skin off your body regardless of what procedure is chosen.
In the end finding the right plastic surgeon may be more important than which actual procedure they choose.
Best,
Mats Hagstrom MD

Jeffrey C. Hamm, MD - Account Suspended · Answer

Hi and welcome to our forum!
From your photos, I note that you appear to demonstrate a full abdomen, hips and flanks with a significant amount of stretch marks and redundant abdominal skin present. Using height and weight data, your BMI is 29.34, an incredible accomplishment!
During pregnancy or with significant weight fluctuation, the abdominal skin is stretched by underlying tissues. Its elastic properties may be exceeded, resulting in rupture of the skin's elastic fibers and irreversible skin stretch. The inelastic skin will not configure or conform, resulting in sag. The damaged skin will be prone to further stretching.
While an abdominoplasty will eliminate redundant skin and soft tissues of your abdomen horizontally, it will not eliminate redundant tissues in a vertical plane. The vertical component of the Fleur-de-lis procedure will address this issue at the cost of an additional vertical anterior midline scar.
If your photos represent an accurate picture of your present condition, I would recommend the Fleur-de-lis procedure.
Best wishes...

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