HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman who is here today for a plastic surgery consultation. The patient had a gastric bypass last September using a Roux-en-Y bypass technique. She has lost approximately 120 pounds and actually is still losing. The patient started at 330 pounds and now weighs 202 pounds. She tells me that her surgeon thinks she could lose another 50 pounds, but she is happy with her current weight. She uses a high-protein diet and small portions. She exercise with walking, ballet, and has just started running. She has been, throughout the past year, plateauing and losing more weight. She lost 10 pounds over the summer. She uses vitamin A and vitamin D but does not have any vitamin deficiencies. She is a G4, P3, and had normal spontaneous vaginal deliveries.
PAST MEDICAL HISTORY: Significant for bipolar disorder. She had no hypertension or diabetes before or after the surgery.
PAST SURGICAL HISTORY: Significant for Roux-en-Y bypass surgery, laparoscopic hysterectomy, lap cholecystectomy, and right carpal tunnel release, as well as tonsillectomy and adenoidectomies.
MEDICATIONS: The patient uses Prozac, Lamictal, and calcium.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a nonsmoker, nondrinker, and nondrug user.
FAMILY HISTORY: Significant for breast cancer in the aunt, grandmother, and great-grandmother and hypertension in her mother.
REVIEW OF SYSTEMS: Reviewed and significant only for weight loss.
PHYSICAL EXAMINATION: The examination reveals that the patient has evidence of a large weight loss. She has a two-roll abdomen, and the inferior aspect of the pannus extends below her mons pubis. The skin has a deflated appearance, and the lower roll extends towards her back. There are well-healed laparoscopic scars anteriorly and significant stretch marks. Examination of the abdomen reveals a rectus diastasis but no hernias present on examination. No rashes are noted.
ASSESSMENT: The patient is status post significant weight loss, still losing weight, not yet appropriate for plastic surgery.
PLAN: We discussed with the patient that we think it is to be commended how much weight she has been able to lose through the gastric bypass as well as her good habits of diet and exercise. She is not yet appropriate for a tummy tuck, as she has not finished her weight loss. As she has not been at that plateau for six months, she risks the possibility of losing more weight and deflating more, and we recommended that she wait six months after she reaches the plateau because it is possible that she could build muscle and continue to lose more fatty tissue as her body adjusts to its new weight.
We discussed that should she have surgery in the time of weight loss, it is possible that she could have a less than satisfactory result because of excess tissue at that site. We then discussed with the patient very briefly that a tummy tuck involves a long scar extending from hip to hip. For her, because her excess continues around to the back, it may be beneficial to go around the back at some point in the future. We also discussed the possibility of a vertical scar anteriorly with a fleur-de-lis abdominoplasty, but we can discuss that further when she returns after she hits her goal.
We also discussed with the patient the risks and benefits of tummy tuck, including pain, infection, bleeding, damage to neighboring structures, need for further operations, asymmetry of the scar, sensory changes of the abdomen, DVT, PE, and dissatisfaction with the result. The patient will need to have medical clearance prior to going through surgery.
