Tips & Tricks

Many who come to the end of their weight loss journeys often ask “How do I get my insurance company to pay for plastic surgery such as a tummy tuck?” This is a very valid question. Recently I shared with a group of weight loss surgery support patients that my insurance covered a portion of my plastic surgery. Another weight loss surgery patient who works at the same place I do and is ready for her plastic work was shocked. She had no idea our insurance would possibly approve the procedure of having an abdominplasty/panniculectomy done. I see the same types of questions on message boards as well.

Here are some suggestions:

• If you have any type of rash or breakdown of skin, visit your PCP (Primary Care Physician) immediately to have it documented in your file. Do not wait too long or else the rash or area will heal up quickly. Visit the doctor each time these breakouts occur as they will help your case with the insurance company. You may also want to request the doctor’s office keep a picture on file, or to document that a picture was taken and you keep the pictures, along with dates taken. (Note: insurance companies frown upon having a plastic surgeon documenting these types of issues because the surgeon has something to gain from it: your and the insurance companies’ money. Therefore, I would not see a plastic surgeon until after you have documentation.)

• The PCP may prescribe some type of ointment, lotion or other topical cream which usually helps to heal the open or chaffed wound, but does not prevent more from occurring. Most insurance companies require patients to have taken some type of medication to ensure all means of treatment have been exhausted before approving reconstructive procedures as medically necessary.

• It is no longer true that a wls patient must wait 18 months post-op to have any type of plastic surgery done. Some surgeons require that you be at a stable weight for 6 months, and others want you to be within 10 – 15% of your goal bodyweight. For example, if you weigh 130 lbs and have a goal of 120, a surgeon would more than likely go ahead with the procedure as a 10% decrease in body weight would not hinder the surgical result. However, I’ve wondered whether the results would have been different if I had waited longer for plastics. My body seems to have shifted in where it carries weight. If you can wait, it might be worth it and provide better results (unlike me as I grew impatient!)

• Have the Plastic Surgeon take pictures and submit a letter to your insurance company EVEN IF YOU THINK IT WILL NOT BE APPROVED! You may be surprised at the findings. My insurance company had a requirement for medical necessity that the pannula hang AT or BELOW the symphsis pubis (pubic bone) region. I did not think I met this requirement. After all, it is very difficult to see yourself as you really are. Even looking straight on in a mirror, I did not know that my pannula hung down so far. The pictures is where the proof was.

• It is not your responsibility to write the letter to your insurance company. The Plastic Surgeon should write a letter, and he has done this enough to know what is necessary, and should include history, diagnosis codes, any problems that is documented in your PCP’s files such as the repeat rashes and breakdown of the skin and open wounds due to rubbing and chaffing.

• I would not suggest going ahead with surgery in hopes of obtaining insurance approval after the fact. Nowadays, most insurance companies mandate that procedures be PRE-authorized. Failure to do so will result in a denial. If your chosen surgeon does not accept insurance and/or will not write a letter to help you get it covered, find someone else (unless you can afford to pay for it yourself).

• Your insurance company may not approve all of the procedures you need or want. My insurance company, Blue Cross Blue Shield of Tennessee, did cover the panniculectomy. They did not cover the muscle repair as they consider it to be cosmetic. I paid my co-payment for the covered portion, plus the non-covered procedure. I had to choose whether I wanted the muscle repair (which I did!). Be prepared to finance or pay for some of the procedures if your insurance will not, though you can always opt to get it done at a later time.

• Make sure your chosen surgeon has done procedures on weight loss surgery patients. Our skin issues are much different and more complex than working on a normal person. If not, it could prove detrimental not only in your results, but in your health as well. Ask your surgeon to provide pictures of his or her work on bariatric patients. If he/she cannot provide pictures, act hesitant to do this, or if they do not have very many to show you, LOOK somewhere else! Bariatric surgery is a hot commodity today, and plastic surgeons want a piece of the pie! It is a sad fact that some physicians just need a few cases to add to their “reportoire” of gastric bypass patients (somewhat like a trophy or line on their resume). This will make them known in the community IF they are successful and produce good results. BUT, I would not want to be a guinea pig for a surgeon who wants to make a name for himself among the gastric community.

Remember, this is YOUR journey, YOUR body, and YOUR health. Plastic surgery is not to be taken lightly. It is a more difficult surgery than the gastric bypass procedure, and often plastic surgery is glossed over or regarded as an easy, elective procedure. Though elective, the recovery time is not a walk in the park.

You’ve spent months possibly years in obtaining your personal weight loss goal. Now you find yourself at a time of altering, change, and adding food back to your diet regime. You have to re-evaluate your goals, set new ones, and it can be frightening because you are entering uncharted territory! One thing you do know very well at this point: how to eat for the purpose of losing weight. You’ve settled into a routine that works best for you, and now those routines now need to be altered in order for you to put the brakes on your weight loss.

There is an overall feeling of fear and anxiety that can grip a person who must add food to their diet. Considering the amount of sacrifice, money, time and effort put into losing a massive amount of weight, it’s of little wonder that to ADD food to one’s diet would cause stress. Even normal people would be concerned at the question “What if I eat too much or the wrong food and gain weight back?” But the gastric bypass patient has other legitimate stressors that normal people do not, such as “What if I stretch my pouch?” or “What if I become addicted to carbohydrates, spiraling out of control?” Last, “What if I gain all my weight back?”

 

The key to maintenance is to add calories very slowly. Adding too much too soon is the quickest way to weight regain. A few short days after I reached my weight loss goal, I contacted my nutritionist who instructed me to add “whole grain breads, low carbohydrates wraps, rice, and milk” to my diet. I began with milk every few days in my protein shakes. I also started to add higher calorie items such as salad dressing, whipped cream and peanut butter. I bought some whole wheat bread (the lowest carb version I could find) and within 3 weeks, I had gained 5 lbs! I was devastated! It didn’t take too long for me to realize that my body could not handle these new additions all at once. (Too much of a good thing can become a bad thing!)

There are some people who continue to lose rapidly and must take drastic measures to stop their body from losing. If not, their weight could fall to an unhealthy level which could cause other problems for them. I never faced this as my weight loss slowed to a crawl toward the end anyway. So I did not need to increase the calories much to end all weight loss.

Continue to journal all food intake. Start with adding a few calories each day. One example would be to add whipped cream to your protein drink. Or, add a higher calorie salad dressing or mayonnaise to your salad, chicken or tuna. Closely monitor your daily caloric intake and the scales to make sure they are not declining. As you add a certain item, and see the scales stop, you will be able to know how many calories it takes for your body to no longer shed weight. However, if the scale jumps a pound or two, you will know just exactly what your daily calories should not exceed. Every weight loss journey person must go through this phase at one point or other. It cannot be avoided! We have to know at what level our bodies stop or gain.

Plan all of your food. Prepare a menu and do not turn to mindless snacking. Something occurred within two months of my “goal”. I thought “Wow, I can treat myself now and have some things that I have not been able to.” Rightly so, I had earned the right to have a taste of pie again. But, this is dangerous because it can get away from you before you realize what has happened and your scales are on the climb!

Realize that it’s OK to obsess over the scale and continue to follow your gastric guidelines. You are as normal as normal can be considering that you are a gastric bypass patient. You will continue to watch your eating throughout your life in order to be a long term success. We have heard too often of those who regained because they wanted to return to “normal” as quickly as possible, and they never altered their eating lifestyles during weight loss mode. Always embrace and hold dear those new routines and habits that you learned so soon after your surgery: protein first, low/moderate carbohydrates in vegetables second, staying clear from simple carbohydrates.

When you do treat yourself to the occasional bite (or three) of a dessert, don’t allow yourself to be overwhelmed or burdened with guilt. You had this surgery to be happy and healthy! You did not have the surgery to be chained to the scales, and live in fear of food. Develop a healthy relationship with your protein filled foods and frequent them often, while enjoy the treats rarely but savoring every bite.

Be cognizant of eating patterns or tendencies such as snacking or eating poor choices. Ask yourself, “Why am I eating this food?” One example is eating when under stress. If you find that you want food for comfort when upset, try to find other healthier ways to deal with problems. You may need a counselor’s assistance. Treat yourself with a massage, pedicure or manicure, buy a new pair of earrings, give yourself a bubble bath. Read a book, look at a magazine, go for a walk, buy great smelling lotions or candles to enjoy. The possibilities are endless.

Many of us view “Maintenance” as the finish line to our weight loss journeys. In many ways, it’s actually just a resting place where we gain our composure, grab a drink for a time of refreshing, and then start chugging along again in the journey. The next phase is almost just as, if not tougher, than the actual first phase! We are forced to come face to face with the reasons we became obese in the first place, and correct those emotional, mental and psychological dependencies to ensure our success.

It’s also a wonderful time because our weight has finally stabilized and we can buy clothes which will remain a permanent fixture in our wardrobe. We now know what we will look like in our bodies: where the loose skin is, what areas will need plastic surgery, etc. However, we continue to struggle for the next six months to two years in accepting and seeing ourselves as “thin” instead of “obese”. The unwanted pounds have been shed; the obese mentality, however, has not. It takes time to change this.

 

Using a food journal can be beneficial in losing weight.  It provides a daily account of the calories, carb, sugars, protein that you consume each day.   And, should your weight loss stall, you have records to analyze which can show where to make changes in your diet.

 

 

Part I - (as showcased on Labrada Nutrition blog, August 2009)

I had a friend who never balanced her checkbook. She never knew if there was enough money in the bank to cover her transactions. She panicked quite often, called her automated teller system to find out which debits and credits had occurred in order to get a “general idea” of her balance. It made me thankful that I didn’t have to live in such a state of emotional upheaval!

I recently realized that basically many people handle their nutritional lifestyle the same way. They play it by ear, never knowing how many calories that they consume in a given day. I hear it often, “I don’t understand why I cannot lose weight. I eat healthy.” Yet, when questioned for a day’s worth of menus, there is nothing healthy about it. Daily, we are faced with food at every turn (fast food, snack food, fried food, carb heavy food, and even “comfort” food). It is imperative that we educate ourselves on the nutritional values of food options as this will help us choose healthier substitutes.

A study was published in the August 2008 issue of American Journal Of Preventive Medicine where two groups of people were examined for a period of time. One group maintained food journals, the other did not. The final determination was made that those who kept a food journal were more successful in losing weight than those who did not. There are valid reasons and positive benefits for those who utilize the tool of a food journal.

Recording every thing you put into your mouth (including food, beverages, condiments, spices, sauces, candy, and dessert) is much like keeping track of your bank account. As you enter food choices, you will be able to tell how much more you can eat and remain on budget. Failure to keep track of the choices could cause a deficit, causing a negative impact such as no weight loss or even weight gain!

I would like to make a challenge. Over the next few days after reading this, begin to write down everything you consume in order to get an accurate reflection of your nutritional intake. You can choose whichever system works best for you, a pad of paper or a website. Two great ones which are free include: Livestrong (formerly The Daily Plate) and Fitday. *It’s easier to enter them all into a computer program because it automatically calculates the math for you. This is the conclusion of part one, but come back soon for Part 2 where we will discuss the results of your “homework”.

Part II - (as showcased on Labrada Nutrition blog, August 2009)

Last time in “Food Journaling – Part 1”, we discussed the importance of balancing our nutritional checkbook. And, left off with a challenge to write down everything you consumed to gain an accurate reflection of your intake. I’ve been curious as to how you fared in the challenge! If you want, please leave some of your observations in the comments section! Let’s start off today by discussing the methods used to journal food.

• Some choose to use a pen/paper method to write down the brand name and amount eaten as the day progresses and come back later to do the figures. The problem arises when researching each item, writing the nutritional values into the blank pages of your journal, and growing weary FAST! It’s a cumbersome task to search foods in a book that gives the proper values, and saving your food labels throughout the day can become messy. If you desire to use this method, visit your local bookstore to find a food journal that best fits your needs (keep in mind that you need space to write in).

• Others choose to utilize online sites such as LiveStrong or Fitday. While these are great programs, unless you have a blackberry or access to the internet 24/7, it’s easy to forget the foods that you’ve consumed by the time you make your way to a computer. (After I had gone to bed at night, I would remember foods that I had not recorded!) However, a few benefits of these types is that the database of foods is endless, and it’s not necessary to have a math degree to be able to calculate the totals!

I’m of the thought that both the pen/paper and online programs are helpful when used together. Throughout the day, jot down your food choices and amounts consumed, while entering them all once you can access the internet.

Next, I want to address accuracy of the food journal. I remember the beginning of my food journaling experience. The nutritionist made it clear how important it was to record EVERY SINGLE THING I put into my mouth. How hard could that be? I ate 3 meals a day, and a few snacks in between. Surely it wouldn’t take me long to enter three items per meal, one item per snack.

Fantasy Journal

Breakfast: eggs, bacon, toast, milk

Lunch: meat, vegetables

Supper: meat, potatoes, vegetable, bread

Nightly snack: 2 scoops of ice cream

In this equation, I not only stayed within my daily budget of calories, I had quite a savings nestegg stored up for another day!

Actual Journal

Breakfast: 2 eggs with salsa, cheese, sour cream, sausage inside a tortilla, 3 slices of bacon, piece of cheese, toast (2 pieces white bread) with lots of butter AND jelly, glass of full fat milk

Mid Morning snack: Bavarian Cream donut

Lunch: Lasagna, brocolli, garlic bread, carbonated beverage, warm pineapple cake

Afternoon snack: daily visit to the work vending machine for 1, perhaps 2 candy bars for a “pick me up”

Drive home from work: bag of chips to avoid a crash

Supper: Chicken breast smothered with cheese, barbecue sauce, onions, bacon on a bun, baked potato with sour cream, butter, chives, sour cream, and cheese, broccoli casserole, 3 rolls with honey butter, 2 glasses of sweet tea

Nightly snack: ice cream with hot fudge, banana, whip cream, or a hot fudge cake from the local restaurant and if I watched a movie, a bag of buttered popcorn with yet another soda

Conclusion

It doesn’t take an accountant to analyze this data and tell me that I had overdrawn on my budget! I was operating in the red! Yet, starting out, I really believed that the numbers on my food journal would be low. (even though I was 5’4, weighed 251 lbs and considered morbidly obese by a medical physician).

Perhaps at the beginning of the challenge, you thought “Oh this will be a breeze. I’m a routine eater, I eat the same thing every day. I bet I am within my budget!” But, the results in black and white (if you were honest) said something completely different! It is important to continue food journaling so that our weight loss efforts will not be sabotaged by poor choices or lack of knowledge. Next time, we will discuss how your food journal results have affected your food choices and amounts consumed.

Before you begin the weight loss journey, it's important to talk about support systems.  Every individual needs a support system, or at least a plan in case motivation is needed.  But, I bet you won't guess who you're number one person of support is!  You'll probably name your doctor, nutritionist, parent, child, sibling...  but your #1 supporter is... YOU!

Read more: Your #1 Supporter

Many people are concerned about the scars left by their weight loss surgery (and later, plastic surgery).  Luckily, I found out about this recipe prior to my weight loss surgery and used it.  I used it (as well as another weight loss friend) on old scars and it diminished their look drastically!  Have an old gallbladder incision?  Breast reduction or other scars?  Try this cream!

Now, if you plan on having plastic surgery, it is possible that with the upper body lift or tummy tuck that the surgeon will be able to remove your scars by skin removal, especially if getting a midline incision (aka anchor cut).  But, for those who cannot afford plastic surgery or want to look great prior to the many months before plastics, this is a great recipe. 

            

Scar Cream Recipe
This recipe was given to me by a business contact. Her mother-in-law works at Vanderbilt and a plastic surgeon there recommends this to his patients. It’s a very simple recipe. However, the Pure Lanolin is difficult to find.

Use equal parts of: (i.e. one cup of each)
(1) extra virgin olive oil
(2) Ponds Cold Cream (I would use Ponds, not a cheaper version)
(3) Pure Lanolin (it’s sold on Iherb.com for less than $5 for a 7 oz jar. The jar is better and makes it easier to apply. The oil makes it messy and runny.

Mix all ingredients together in a plastic container. It’s very hard to stir as the Lanolin is almost like wax. I just filled up the jar which the Lanolin came in and use that to dip my cream from each application. The rest can remain in the plastic container until you are ready for a refill.

NOTE:
I have read on the Make Me Heal forums and also recently another friend of mine posted this...it's been suggested that the actual cream used does not matter.  Whether this is true or not, I still love THIS RECIPE!!  It makes my skin feel so soft and smooth.  But, supposedly it's the pressure which is applied to the scarred area that promotes healing to scars.

My plastic surgeon had instructed me to massage the cream of my choice into the scar but I didn't think too much about it. I started seeing results even on old scars and thought it was my choice of scar cream (see recipe above). Now, it's said that the actual massaging or pressure helps blood flow to the area, which helps healing.

In the beginning, I faithfully applied the scar cream twice a day. But due to the numbness and tingling sensation, I could not massage it properly. I just sort of rubbed lotion on and spread it out. If/when you have plastic surgery, you will see what I mean because the tummy/abdomenal region is sensitive yet tingly yet numb. It is a weird sensation. But now, I actually massage the cream into the scar and work my way across the stomach area and then back again. Now I have feeling and it's not uncomfortable.

One email I recieved asked the question about plastic surgery which said:  "I am considering WLS, and have questions about the excess skin that comes with weight loss. Your blog makes it sound like that plastic surgery is a must for most people who have had WLS - is it?"

Read more: Plastics - Will I Need?

There seems to be MANY hoops to jump through in order to have gastric bypass surgery.  Insurance companies have tightened their purse strings and requiring 6 month pre-op diets, 10% excess body weight loss, and a list of co-morbidities.  By the time you get the word that you've been approved, it's an emotional relief...  one that brings many to tears because of the hope that their life is about to change.

Read more: You've Been Approved!

Pictures are important; they are reminders of our past (where we have been).  If used properly, they can take us into the future (where we want to go).

Several years ago, my mother decided to sort all of her photographs and give them to her four children.  She asked for my thoughts, suggestions and help.  So, I purchased four decorative photo boxes and together we began the task of sorting the pictures.  As we sat in the midst of photo albums, I realized there were plenty of pictures of every child except me.  I noticed that in the late junior high years, the photos became scarce.  This made me somewhat sad and resentful towards myself.  I knew that it was about the time that I started to gain weight, and as a result I dodged the cameras, not wanting my photo to be taken. There were about fifteen years of my life that only a few pictures exist. 

Perhaps you can relate because you too have been a picture dodger.  Most often, as a person notices weight gain, his/her self esteem starts to decrease.  Feelings of shame arise because of one's appearance, and the last thing anyone wants is a visual aid to prove that there are pounds that need to be lost!  At first, the attitude is, “I’m going to lose some weight, THEN let them take my picture when I look better!”  Years pass and the weight wasn’t lost, or perhaps more weight was gained.  Many photo opportunities were missed, and the events which you held so dear were not captured on film.  Instead, the memories are preserved only in the minds of those who attended.  

You should get out your photo albums, or maybe ask your parents, siblings to view theirs.  See just how many pictures there are of you, and try to determine the period of time when the picture taking dropped off.  More than likely, it was when you gained some weight.  It’s only natural that when you feel poorly about yourself, you don’t want a photo op as it serves as a reminder to you.  Is it also possible that you felt just a little embarrassed for others to see pictures of you while overweight? 

My first post-op picture was taken two months after my weight loss surgery.  I attended my gastric surgeon's Christmas party and dressed up specifically for the occasion.  A few weeks later, I showed my dear friend, Jan, my official before and the Christmas party pictures.  I remember a hot embarrassment came across my face, and I could hardly breathe.  For the first time, I realized how big I had gotten before my gastric bypass, and I felt ashamed to have let myself get in that condition!  But as the weight was shed, that before picture became my beacon, theme, anthem, banner...  Here are a few pictures for you to see the changes which occurred.  Just remember, the feelings that these photos evoke now in you, it will be the same feelings you will have as your own photos are set side by side! (HOPEFULLY you thought, "Wow!" LOL)

       

I have a homework assignment for you.  You may not like this idea because it deals with pictures.  But in order to have an accurate reflection of where you have been, where you currently are and where you want to be on your journey, you need to have pictures taken on a consistent basis.  If you are about to start your weight loss efforts, it is important to have a “before” picture taken.  Then as each month passes, you can have a new picture to gauge your progress.  You can lay the "before" and current picture down beside one another so that you can see the difference with your own two eyes.  Now, it is possible that for the first few months, you will not be able to see that much of a difference.  This is because the weight is coming off of EVERY area and its not as noticeable (in other words, you won’t see your spare tire disappear completely even though that’s the area you wanted to dissolve!).  But other people will definitely say “wow, yes there is a big difference!”  It's hard for each of us to see ourselves as we really are; sometimes it takes someone else to provide some inspiration. 

1.  Choose your favorite outfit, one that you will keep throughout your weight loss journey.  After you’ve taken your official “before” photo, put this outfit into a box inside your closet for safe keeping.  The outfit should be one that fits properly and shows your real shape.  This outfit should not be really loose or tight fitting.  Try to get an outfit that is pretty accurate to your size.  Many overweight people tend to wear clothes that are too big so that they appear smaller (when really, it doesn’t work).

 2.  Have several pose shots taken.  There are four  that work best: 

• front

• side view

• front/side view which is about a 45 degree angle

• back

3.  *Try to reproduce the same environment for every photo.  Every month, have the picture taken in the same room, from the same distance away from the camera.  This will prevent any skewed images.

4.  Stand up straight, don’t slouch.  You want to create a photo that is true to life and shows your real shape so that in the future, you will be able to see how much you have lost.  Slouching can make your stomach appear larger.  Don’t “suck” it in or hold your breath, but have a natural stance.  I’m sure you’ve seen diet pill ads where the individual has on a bathing suit, and you can tell that they are pushing their stomach out in the “before”.  Then the picture right next to it looks exactly the same, wearing the same bathing suit, only they have a flat stomach and look as if they are holding their breath and sucking their tummy in. This does not help you see the REAL results.  Besides, if many of us could go around sucking our guts in all the time, we would!  But that is not a very comfortable way to live.

5.  Make sure there is good lighting.  While the picture does not have to be taken by a professional by any means, you will want this to be a clear picture.  You will hold this photo near and dear for many years to come, possibly even showing it to many people once your goals are met.

6.  Take pictures every month during your journey.  That way you can look back on your progress.

7.  Carry your before and current pictures with you.  Keep it in your purse, a notebook, binder, some sort of calendar, or wallet.  This will help you when times of discouragement come.  When you begin to feel that you haven’t accomplished very much, just pull out your trusty pictures and it will encourage you!  And, you never know when you will be asked by someone if you have a before picture with you.  I still have my driver's license from when I was overweight, and at times clerks have asked, "Is this really you?"  And I respond, "Yes." They want to know HOW I changed so much. I sometimes pull out my official before/after photos and it amazes and inspires them.  Of course, I also hand out my business cards to drum up some website hits!