Frequently Asked Questions (FAQ) The following are some brief answers to what we have seen over the years to be the most commonly asked questions by those considering weight loss surgery. Most of this section covers topics which are not covered elsewhere. Likewise, the content elsewhere in this site is not repeated here. Unlike the remainder of this website, answers have been formulated from a combination of the surgical literature as well as the author’s personal experience. Some answers may even be specific only to this practice and may not even apply to other bariatric surgery centers. Certainly, if any question is not included or fully answered in this section or the remainder of this site, please feel free to contact us. It is our goal that you have a full understanding of bariatric surgery and we will do our best to accommodate you in that regard.
What about the excess skin?
This question is far and away the most common question asked of us in reference to weight loss surgery. Further, there are many misconceptions concerning this phenomenon. Any adult who loses a massive amount of weight will have some redundant skin. This is because the skin of an adult lacks the elastin necessary to stretch back. The amount of redundant skin is a function of two things: the body habitus of the individual and the amount of weight which is lost. For example, if one carries most excess skin in the abdomen, there will certainly be redundant skin in that location after massive weight loss. In those whose weight is distributed more evenly, this affect will be less pronounced. However, more important is the amount of weight lost. In our experience, it is not until about 50% excess weight loss that the excess skin becomes noticeable. It is for this reason that most patients after a laparoscopic banding will have fewer issues with their skin than those undergoing procedures that produce more profound weight loss. Further many people believe that exercise “tones up” this excess skin. This is a complete inaccuracy. Although we believe daily exercise to be paramount importance for success, it does nothing to reduce excess skin. In the end, if you develop areas of excess skin postoperatively, that is cause to celebrate as this means you have done well and have lost massive amounts of weight. The only reasonable option for this condition is body contouring surgery. It is truly amazing what can be done surgically to remove and reshape this excess skin and we have plenty of resources to aid in accommodating this process. Our recommendation is to make plans for proceeding with body contouring approximately 18-24 months after surgical weight loss.
Will my insurance pay for plastic surgery?
The short answer to this is probably not. Body contouring is generally considered cosmetic surgery and therefore not covered by commercial health insurance. The exception would be for “medical necessity”. In that regard, this usually involves situations where chronic, recurrent skin infections can be documented and therefore justify skin removal. However, even in that case, the covered benefit general involves a procedure that involves simply cutting off the excess skin (panniculectomy), rather than one which involves contouring of the abdominal wall (an abdominoplasty). Further, procedures involving the arms, legs and breasts are generally considered elective and not covered by insurance carries. Many have the false idea that if they have a hernia from their weight loss surgery that needs repaired, then plastic surgery can be included for free as well. Likewise, this is not true. In those situations, fees are typically prorated such that the plastic surgery portion of the procedure is paid for by the patient. In addition, many have inquired as to the opportunity to “donate” their excess skin in return for receiving skin reduction surgery free of charge. Although this has been brought up a multitude of times in our experience, we have yet to find a situation where this is the case. In general, we counsel our patients in this way: if you do as well as we hope you do, and know you can, you will have some redundant skin. If this is something that you will want addressed, start saving early, for this opportunity will be there within 12-18 months.
What about hair loss?
Some hair loss is very common during periods of rapid weight loss. Many patients believe this to be because of malnutrition or poor protein intake. This is usually not the case. Hair follicles are always in either a growth phase (anogen) or inactive phase (telogen). All follicles start in anogen and after about 100 days go into telogen, at which time hair falls out. In bariatric patients, this process is accelerated, causing hair loss. The causes of this acceleration are varied and include medications, child birth, fever, thyroid disease, and rapid weight loss. However, it can also be caused by low protein intake as well as iron, zinc, fatty acid and vitamin B12 deficiency.
Hair loss after bariatric surgery occurs between the third and sixth month and lasts 6-12 months, essentially encompassing the rapid weight loss phase. In general, the follicle suffers no harm, so when weight loss settles down, then hair growth returns. However, since there are several deficiencies that can be associated with this phenomenon, we recommend laboratory analysis along with the following recommendation: 80g daily protein, 15ml flax seed oil, 2-5g biotin, 500mcg daily vitamin B12 and 325mg iron. In the end, as stated above, hair loss is usually a side effect of rapid weight loss, it is generally only noticeably to the patient themselves, and this process reverses when the weight loss slows down.
What if I want to get pregnant?
The literature is replete with studies in relation to weight loss surgery and pregnancy. This is a common concern for many young women who look forward to starting a family. The common notion is that weight loss surgery will cause difficulty with pregnancy, especially in terms of adequate nutrition. On the contrary, all studies have shown that weight loss surgery is beneficial in relation to pregnancy and child birth. This is in fact true, when looked at from multiple angles:
- One will have a better chance of getting pregnant after weight loss surgery.
- One will gain less weight during pregnancy.
- It will be easier to achieve a normal post-pregnancy weight.
- The chances of having to undergo c-section are less.
- If a c-section is done, the complications will be less.
- The chance of peri-partum complications for the mother and the baby are both less.
- The baby will be healthier than if born to a mother who is morbidly obese.
- Neither the child nor the mother will suffer malnutrition.
The above data are based primarily on studies concerning gastric bypass and pregnancy, but would certainly hold true in relation to laparoscopic banding or sleeve gastrectomy. The only difference with banding is that after gastric banding we often recommend removing fluid from the band for the first trimester, such that if the mother develops excessive nausea and vomiting (hyperemesis gravidarum), it does not promote a “slip”, and therefore necessitating an urgent surgery during this portion of the pregnancy. Notably, one often doesn’t know she is pregnant until at least four weeks into the first trimester, so fluid removal is often only performed for about a month.
One very common misconception is that banding is “safer” if one is considering pregnancy. This notion is completely false and was actually born out of a marketing strategy for laparoscopic banding rather than clinical data. Overall, when looking at weight loss surgery in relation to pregnancy and child birth, it is all positive.
What is the recovery time?
Postoperative recovery is different for everybody. A typical hospital is 24 hours for laparoscopic banding and 48 hours for gastric bypass and sleeve gastrectomy. Return to work will be within 2-3 weeks on average. There is, however, a significant variability between individuals in that regard. We have seen some return as soon as one week, and others require six, eight or twelve weeks off. In our experience, most employers will allow four weeks off. If the procedure is performed laparoscopically, unrestricted activity can be resumed as soon as the patient feels comfortable, usually within a couple weeks. If the procedure is performed in an open manner, lifting will need to be restricted to less than ten pounds for six weeks as to decrease the change of developing an incisional hernia. This may delay return to work for those who have a rigorous occupation. In the end, return to full activity is much more a function of individual factors than any stringent guidelines.
How long after consultation until I get my surgery?
The time period between an initial consultation to surgery is quite variable and is usually anywhere between three and twelve months. This time period is dependent upon multiple variables, mostly having to do with accomplishing the workup that may be required by the program or your insurance carrier. By far, the most common reason for delay is the frequent requirement for a “supervised diet” preoperatively. Most major insurance carriers require some sort of documentation that an individual has undergone a medical weight loss plan prior to approving bariatric surgery. In addition, usually this will need to be supervised by one’s primary physician. Further, the typical requirement is for three to six consecutive months. Some carriers have even required up to twelve months. Submission for approval cannot be done until this has been accomplished. In addition, there is really no way around this requirement. Many patients find this very discouraging. This is certainly understandable, but our advice is to fully review your insurance requirements in this regard to bariatric surgery and get started on these even prior to your initial consultation.
Can you work with my insurance carrier to get me approved?
We have the experts on staff to guide you through the process of getting you approved for weight loss surgery through your insurance carrier. We will submit all the necessary paperwork and help you accomplish the prerequisite steps toward getting surgery accomplished. Additionally, we will assist you in the appeals process, if that becomes necessary. However, whether one has insurance benefits for weight loss surgery is completely dependent upon the details of one’s specific plan. Whether or not bariatric surgery is part of any given policy is clearly spelled out in one’s delineation of benefits. Unfortunately, many individual plans directly exclude bariatric surgery benefits even if the carrier as a whole provides coverage for surgical weight loss. If this is the case, no amount of appeals or negotiation will convince a carrier otherwise. If you are planning to pay for weight loss surgery through your insurance carrier, it is very important that you have a clear understanding of the specifics of your policy beforehand. We will be very happy to assist you in that regard.
Isn’t bariatric surgery dangerous?
Bariatric surgery, especially gastric bypass, has the reputation of being “high risk” surgery. Indeed, it is major gastrointestinal surgery and as with any surgery, risks are unavoidable. However, the risk of succumbing to a complication of morbid obesity far outweighs the risk of surgery. Current studies show that the thirty day mortality for any bariatric procedure is around .1-.3% (1-3 in 1,000). This is equivalent to many procedures done every day such as gallbladder surgery, hysterectomy, and hip surgery. In fact, weight loss surgery is up to ten-fold safer than procedures like colon resection, esophageal surgery and cardiac surgery. Conversely, no other procedure can come close to providing the multitude of benefits that can be offered through weight loss surgery. Indeed, multiple studies now show that if you undergo weight loss surgery for morbid obesity, you will be enjoying up to 90% resolution or improvement of multiple comorbidities and your chance of being alive in five years is up to 40-90% higher than it otherwise would be. Indeed, the risks of surgery are important to understand and grapple with in making a decision for weight loss surgery. However, they are far less than the risks associated with continuing to suffer the disease of morbid obesity.
How does your body know to stop losing weight after weight loss surgery?
This is a good question, and the answer is not entirely clear. However, we believe it has to do with both the way weight loss surgery changes one’s anatomy and physiology, as well as minor changes that occur over the first two years after weight loss surgery. The mechanisms for initial weight loss are explained elsewhere in this site (see “Why Choose Surgery”). After several months, the pouch and bypassed intestine accommodate such that a little more food can be taken in at a time and calories are absorbed more efficiently. As a result, a balance is achieved and weight loss stabilizes. In addition, a further explanation can be seen by the “set point theory” of obesity. Recent research suggests that the cause of obesity has to do with a changing of the set point where one’s weight is stabilized. Because of multiple genetic, environmental, and lifestyle influences, obesity results from the normal set point for one’s weight being inappropriately elevated. Many believe that weight loss surgery, through its multiple physiologic and anatomic effects, actually reduces a given set point to near normal levels. Once that set point is thus achieved, weight loss stabilizes. Further, it should be noted that the new set point is just as subject to the same environmental and lifestyle factors as one would be prior to surgery. Thus, it has been shown that maintaining a new weight will require continued effort. It has been shown that if a gastric bypass patient starts consuming more than over 1,000 calories a day, weight may start coming back on. In addition, it is very rare to see patients lose too much weight after weight loss surgery. Indeed, the challenge is not stopping the weight loss, rather it is the opposite. It is fairly easy to “eat around” any weight loss surgery, but a life of continued dietary discipline and healthy choices will keep you at your goal weight once you get there.
How can people regain their weight after weight loss surgery (and how can I not be one of them)?
Overall, weight loss surgery is successful in about 80% (as defined as maintaining 50% excess weight loss). This is, of course, compared to medical therapy, which carries a 95% failure rate. It is true that it is not uncommon to gain 10-20 pounds from one’s lowest weight. However unfortunately, 10-20% will gain most, if not all of their weight back. Why? This is best answered by examining those who have not. For years, the National Weight Control Registry has been tracking the habits of those who have lost large amounts of weight and kept it off. Several habits are consistently seen in this group: They generally eat several small meals, they stay away from sweets and fried foods, they weigh themselves 1-2 times per weeks, they drink a lot of water, and exercise up to one hour daily (yes, daily). Indeed, over the years we have found that for those who do follow these habits, weight regain is exceedingly rare. Conversely, for those who regain their weight, we have also seen very consistent trends. In general, there is a lack of dietary discipline, no organized exercise regimen, and a general belief that life stressors are to blame for the inability to maintain healthy habits. It is very easy to “eat around” any given weight loss surgery, and often tempting to find reasons to do so. In the end, the key to success if found in a life of daily healthy choices and discipline. Weight loss surgery is only the first step of the rest of one’s life and it is up to you to take charge from there.
Are there any detrimental effects long-term with the Gastric Bypass or Band?
For gastric bypass, none that we know of, as long as one takes the recommended vitamin supplements. For laparoscopic band, we don’t think so. There are no reports of the band “wearing out” with almost 20 years of accumulated experience thus far world-wide.
Don’t you have to take vitamins?
Gastric Bypass – yes
Band – no
Sleeve – no
Doesn’t Gastric Bypass make you malnourished?
No, as long as the procedure is performed properly without bypassing too much intestine. However, there are several vitamin deficiencies that will likely occur if one does not take a multi-vitamin, Vitamin B12 supplement, and calcium. Further, a daily iron supplement may be required if, in fact, that becomes deficient. However, as for protein malnutrition, this is exceedingly rare after Gastric Bypass, only seen in about 1% of patients.
Do I really need to exercise?
Yes, unless of course you don’t want to reach your goals. Understandably, the process of daily rigorous exercise is completely out of the question for many people seeking weight loss surgery. However, three to six months postoperatively, with thirty to fifty pounds weight lost, this goal becomes much more achievable. In that regard, my recommendation is this: start slow, be persistent, never give up, and you will be amazed at what you can accomplish. Indeed, it has been shown that the vast majority of those who lose massive amounts of weight and keep it off long-term exercise up to one hour daily.
Isn’t bariatric surgery the easy way out?
No, but at the current time, it does appear to be the only way out. Bariatric surgery certainly is not a venture for the faint of heart or those who are looking for a short cut to success. As stated elsewhere in this site, we believe that success is critically dependent o on a life of daily discipline, including healthy dietary habits and regular exercise. Currently, these are the habits of less than 5% of the U.S. population. The vast majority of those who are successful after weight loss surgery know the life that is profoundly more disciplined than those around them. However, the fullness of life achieved in return is worth every effort.