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Dr. Jones: So you've been very successful at achieving your weight loss goal. Congratulations. But you don't fill out your bra anymore. What is that about?

Most women who undertake a significant weight loss through diet or through weight loss surgery are hoping to lose fat. That's the part of the body that we don't need so much. We don't want to lose a lot of muscle when we do a weight loss thing. But some parts of our body are mostly fat, and that would be our breasts, and weight loss may lead to a body change that isn't welcome. So what can we do about that?

Today, in the virtual Scope Studio, I'm talking with Dr. Cori Agarwal. She is a plastic surgeon who specializes in aesthetic and reconstructive surgery at the University of Utah, and she has an interest in helping women find the body that they're looking for.

So I have some questions about this, because this is a really interesting topic for people who have really undergone a basic transformation of their body, whether it was 30 or 50 pounds, or they lost baby weight and the baby and then they nursed and so their body isn't the same. After substantial weight loss, women may find their bodies change in ways that they hadn't anticipated. Can you talk about weight loss and how it affects breast structure?

Dr. Agarwal: I think that's a really overlooked conversation when people set out to lose weight. They're really focused on health and kind of the getting back to feeling more active. And sometimes it's a surprise when there's this negative effect on specifically the breasts.

The breasts, as you mentioned earlier, are made up of quite a bit of fatty tissue, and that really varies person to person. But I'd say most women, especially as we age, the breasts become more and more percentage of fat. So when you lose weight all over your body and you lose fatty weight, naturally some amount of that is going to come off of the breasts. And you don't always know until you're there. So, for some women, it's just a minor effect. And for some, it's completely deflated after the weight loss.

Dr. Jones: Oh, deflated. I mean, it's hard enough getting older and if you've had babies, but to have . . . even that word deflated, that would have me rushing to you to get some help.

Dr. Agarwal: Well, I was going to say the deflation, it's really important to think of it in two areas. There is the loss of volume, so the loss of this fat where you really just lose the size of your breast. And then there's the deflation, the sagging of the skin where the nipples kind of point down and everything stretches down.

And those two we really think of separately and independently. When we talk what options there are for rejuvenating and filling the breasts, we really think of the sagging and the loss of volume separately, because not every individual has as much sagging or as much loss of volume.

Dr. Jones: When you said there are really two parts to two different kinds of changes that happen with weight loss, there's sagging and then volume, what are you going to do? What are the procedures here that you're going to undertake with this woman?

Dr. Agarwal: There are really two main objectives. And one is to fill the volume to the size that was lost. And for some women, they want to be a little bit smaller than they were to start. Some want to be a little bit bigger. And to fill that volume back, to restore that deflated volume, the mainstay operation is a breast augmentation, and that's placing an implant in the breast usually behind the muscle to regain the volume.

However, if the skin has at the same time sagged, which it usually does, in the process, there needs to be a skin tightening procedure done at the same time. And that's called a mastopexy or breast lift.

Now, these can be done independently. Someone may just want the lift. They might like the size that they've ended up, but everything's just droopy. So we'll just do the breast lift. And then more commonly, we will offer and recommend a lift with an implant, because in most people, I think both of those processes are happening. That's something that's very individualized, but I think it's important to think of those two separately, the lift and the augmentation.

Dr. Jones: And so, rather than some people thinking they're just going to have a little incision somewhere and something is going to be slipped in and pumped up or something, you're really going to have to remove some skin and maybe lift the nipple.

Dr. Agarwal: Right. I think that's often a surprise for women because they think, "Well, this is just like a deflated balloon. I'm just going to fill up the balloon," but they haven't really noticed how far things have stretched. And we really have to have an honest conversation about what it will look like with just the implant, or if you really want or would recommend a lift along with that implant.

Dr. Jones: So what are the options for women who would choose breast surgery? Do you call it aesthetic or cosmetic, or in this case, is it really reconstructive and is it paid for by insurance?

Dr. Agarwal: That's a really important thing, and so many things are blurred in the world of plastic and reconstructive surgery. A lot of things that we do that are reconstructive really are also cosmetic, and there is a blurred line, especially when it comes to the breast.

So when we talk about the words cosmetic and reconstructive, what we're usually getting to is "Will insurance pay for it?" Because if insurance sees it as cosmetic, then even if we think it's really truly a reconstructive thing, building your body back, we have to call it cosmetic. And the sad truth is that for most breasts that have sagged or lost volume almost all the time will be considered cosmetic by insurance companies and is not covered.

Dr. Jones: Well, for women who part of their weight loss journey has been becoming really active, and now they have breasts that don't want to stay where they want to put them, that ends up getting in the way of their being the physically active person that they have to be if they're going to maintain their weight loss.

Dr. Agarwal: Right. And we do try to make those arguments to insurance, but I think that it's just outside the scope of what we can declare medically necessary for the breast. Breasts sag for so many reasons. Pretty much anyone who has gone through a pregnancy and nursed a baby, even just age, breasts just sag almost 100% of the time. And so I think that's just beyond what we can argue for insurance to cover.

Dr. Jones: Knowing that many people who lose weight gain it back again, is there any recommendation about waiting for weight to stabilize for a while before considering breast augmentation? I mean, we've all watched the successes and failures on "The Biggest Loser," and some people are back right where they started from within a year or two. So how do you counsel people in terms of when they should consider this reconstruction?

Dr. Agarwal: I think as a general rule of thumb after a lot of weight loss, we'd like people to maintain their weight for about six months. If it's just a quick diet that's severe and maybe they're going to bounce right back in a couple of months . . . but by six months of sustained weight loss, most people are pretty steady in their weight. So that's the general recommendation, but of course, it's very individualized.

Dr. Jones: Right. And can this surgery be part of a larger surgery? So you certainly know people who have maybe had bariatric surgery and they lost 150 pounds, and now they have sagging not just in their breasts, but throughout skin, all over their body, which becomes a significant issue in just terms of staying healthy. Can you do redundant skin reduction at the same time that you do a breast surgery, or are these staged at different times?

Dr. Agarwal: I think both are true for each individual. When we're thinking about doing reduction of skin, tightening of skin after a lot of weight loss, safety is the main priority. We want to limit the amount of time under anesthesia for any individuals. So if they came in and said, "I want my breasts and my belly and my thighs and my back," we really have to slow it down and say, "Okay, what's the most important thing here? Can we combine it with something else?"

We try to limit the surgery time somewhere between three and six hours. And so we can do sometimes breast work with something else, but depending on what other areas are the priorities, it's very common to stage this.

But that's the conversation we have after we get to know the patient and see how healthy they are, how prepared they are for a long recovery. So it can go both ways.

Dr. Jones: So when you say how healthy they are and how emotionally prepared, it's hard when you have just a few minutes to get to know someone. And I know that sometimes before people undergo bariatric surgery, they might actually see a behavioral psychologist. But how do you get to know people to know that this is the right thing for them to do and they're not just seeking something that's really unobtainable? How do you set realistic expectations about what they're hoping for?

Dr. Agarwal: This is really important. We spend a lot of time . . . I'd say the first visit is usually about an hour. And during that time, a portion of it is talking about the surgery and evaluating them. But a big part of it is talking about how they've gotten to that point, how they feel, what their expectations are, and then their social support. I think social support is critical when you talk about getting through a big surgery like that. And so we'll make sure that they've really thought through who needs to help them, someone to help with the children, someone to help with themselves and their work. So that first visit, we do a fair amount of that really trying to get to know someone.

And you're right, it's only one visit, but usually we have another one or two visits after that before surgery and really get to these critical questions of whether they've thought this through and have the support on the other side. Some will have to really set realistic expectations, that you will not have a 20-year-old body after this, but you will have this and you won't have that. So we try to be really realistic and not try to sugarcoat it or make it seem better or easier than it will be.

Dr. Jones: Right. Well, I would think that most people having gone through . . . particularly if it was significant weight loss, they've been with this body for a while and they know what they're looking for, and I bet you they're mostly pretty realistic. They're not coming in with perfect breasts hoping for more perfect breasts.

Dr. Agarwal: I wish that was the case in everyone. I think there are certainly a lot of women who are exactly in that category, but there are a lot of people who still . . . maybe it's a lot of the TV shows out there, but there is an idea that there's some magic that happens and some Photoshopping. I do think we have to ground them sometimes if maybe what they've been seeing isn't realistic, because . . .

Dr. Jones: I've seen some of those YouTube videos, the befores and the afters, and I look at the afters and say, "How can she have lost 150 pounds and have breasts and legs that look like that? Is that real?"

Dr. Agarwal: Exactly. So you have to take a lot of it with a grain of salt, and so that's the job. I think that that's the consultation. You're not going to know that before really meeting with your surgeon and understanding what can be achieved.

Dr. Jones: I want to thank you because I hadn't really thought about this one. Certainly I've had patients over the years who were thinking about bariatric surgery, and I didn't really take them through all the steps that this will happen when you get there. You will get there, but then this may happen. It may not. So I want to thank you for giving us some insight.

And for women who've taken the big steps to make a big positive change in their body through weight loss, there are sometimes still steps to take to feel like yourself again. You're not alone and there are options and procedures that can help.

I want to thank you, Dr. Agarwal, for joining us. And thanks for everyone who's listening on The Scope.