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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.

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: So you look in the mirror and you're starting to see the signs of aging on your face. What options are available to you at any point in life? I'm here with Dr. Cori Agarwal. She is an Associate Professor of Plastic Surgery at the University of Utah Health. So Dr. Agarwal, what are the kinds of people that are coming in for facelifts or rejuvenations? Is there a particular age, or is it all across the board?

Dr. Agarwal: It's definitely all across the board. I think when people start to see their face change at all, there is a little bit of panic that age is coming and they want to come in and see what their options are to slow things down or maintain their youth as long as possible. So we get people even in their 20s or 30s who may be seeing new wrinkles show up and asking what could be done and is it time for a surgery or what other options we can offer them.

Interviewer: At 20 or 30, what kind of things are we seeing? Are we, you know, just a little wrinkles and stuff and what options are available for, say, that age group?

Dr. Agarwal: So in that age group, it would be rare to have a full face lift recommended, but it's very common that you would benefit from things like Botox, which relax the wrinkle lines and maybe fillers that would soften some of the early wrinkles that you would get at those early ages. Other options at those ages would be products that can rejuvenate the skin, like Retin-A, some light chemical peels, things short of surgery.

Interviewer: So we're not looking at a full face change, you know, pull everything back up. It's these small rejuvenation type changes for that age group.

Dr. Agarwal: Yeah. And one thing to point out though is that everyone does age differently. I think a lot of it comes down to your genetics, your exposure to the outdoors and the sun and wind. People can age earlier. So sometimes in the 30s, that decade, people will benefit from a small surgery of some kind, and it's worth coming in and talking to your surgeon at that point if you have certain areas that are starting to sag or droop.

Interviewer: So when you get into the you said a small surgery, I've heard mini facelift or what kind of small surgeries are available?

Dr. Agarwal: Smaller surgeries could be something like eyelid lift, blepharoplasty where there's just a little bit of extra skin. If there is such a thing as a mini facelift, that really focuses on the middle portion of the face, less so on the neck. And another option is facial fat grafting where you're just plumping up some areas, like the cheeks, possibly to add some a youthfulness.

Interviewer: So besides these fillers and, you know, smaller surgeries and other options available, what is the age that most people are getting, say, the full facelift?

Dr. Agarwal: There isn't an absolute age, but I think we start to see people coming in who would benefit from a lift somewhere in the late 40s, 50s. I think those decades, the neck becomes more lax, and I think it's when the jowls form and the neck becomes lax that you're really looking at needing something more rather than just use more minimal techniques to correct that. If you have extra skin hanging in the jowls and neck, you're probably going to do best with a facelift.

Interviewer: So say a patient is looking in the mirror and they're seeing some of the signs of aging, what's the first step that they should do to find out what procedures are even available to them?

Dr. Agarwal: So I think the best advice for that individual is to go in and have a consultation and talk to your surgeon and learn what's out there, learn about what may be best for you, what you're looking for, for your skin type, for your age and I think you can come up with a plan. And you may combine surgery with some of these resurfacing or noninvasive techniques out there to really optimize your result.

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Interviewer: So you've decided to get a rhinoplasty. How long can you expect to see the results that you were hoping for?

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: I'm here with Dr. Cori Agarwal. She is an associate professor of plastic surgery at the University of Utah Health. So, Dr. Agarwal, what can I expect right after surgery when I get my rhinoplasty?

Dr. Agarwal: So rhinoplasty is an outpatient surgery. And depending on how complex it is and all of the work that you're planning on getting, it can take a couple of hours under general anesthesia typically, and you would go home after that surgery the same day. Right after the surgery, you're going to have some bandages on and a splint on the outside of your nose that's going to be taped onto your cheek, sometimes taped onto your forehead. You may have some blood dripping from the nostrils and a gauze under there. So right after the surgery, you're not going to be looking your best. You'll go home and the main thing for the first couple of days is really to just take it easy and let things heal so that there isn't any bleeding or complications.

Interviewer: After the first few days, do the bandages come off? What's after those first few days?

Dr. Agarwal: So it depends a bit on how much work is done. If there's work done on the bones to narrow the nose or just on the soft tissues, so that'll vary a little bit. But, in general, I think, as a rule, most patients after rhinoplasty have a splint or a bandage on their nose for one week. So that's one week having a little cast on the outside of your nose where you're probably not going to want to be going out and doing a lot of social events. You want that splint to stay stuck on, so you don't want a lot of moisture on it. So that first week, I don't recommend making any plans.

Interviewer: So I assume there's going to be some swelling, and I assume there's going to be some discomfort. Is there anything during that first week or so that patients can do to kind of help speed up their recovery at all?

Dr. Agarwal: To minimize swelling, keeping your head elevated can help. And so what I ask patient to do, when they go home, is to get themselves kind of a nest to sleep in, where they have a few extra pillows behind their back or sleep in a recliner. Because when you lay flat, the swelling increases and you can . . . it's a little bit better if you keep your head elevated for those first couple of days while you go through the peak swelling time period.

Interviewer: And what about after those first few weeks? When does that splint finally come off?

Dr. Agarwal: So normally, between five and seven days, you'll go in for your follow-up visit with your surgeon, and they'll take the splint off, take out any stitches that need to come out. And at that point, you're going to be a lot more presentable. You will have still some swelling and possibly some bruising. You can have some bruising under your eyes sometimes, so you may need to put on some cover-up. But at that point, after one week, you can usually go back to work as long as you're not doing anything very strenuous or heavy lifting.

Interviewer: So once they take the splint off, is it just you're ready to go, like these are the results you wanted, or my understanding is that it takes a while?

Dr. Agarwal: Yeah. That's the thing that people don't always understand. And I really try to emphasize before the surgery to set the expectations. But the nose holds onto swelling longer than other parts of the body. And it's also right there in the front of your face. And so even a tiny bit of swelling you're going to recognize.

And so, usually, you're not going to look terrible after one week. But after a couple of weeks go by, the swelling is going to be very subtle to where mostly you're going to be noticing it or maybe some close friends or family would notice it. But it'll be a very small amount of swelling left after about three weeks. But that last bit of swelling, that last little bit takes about a year to go away. And so if you're looking for kind of that final best results of your nose, you have to be pretty patient.

Interviewer: A whole year? It's that last little bit of swelling. Why does the nose hold onto the swelling for so long?

Dr. Agarwal: That's just that the nature of the skin particularly on the tip of the nose can get boggy. Again, it's a very small amount of swelling, and it may not be too noticeable to the world. But when you're looking for your final result, it just takes that amount of time to see that final result.

Interviewer: So for patients that want to get a rhinoplasty, what's the one thing you would make sure to tell them to make sure that their expectations are where they need to be and that they'll be happy with the results?

Dr. Agarwal: So I think after the surgery, it's really important to make sure that you have . . . for the first week or so, you're in a healing period to make sure that you've set aside time off of work and that you have friends and family to help you out. And you'll slowly get back to normal between the first and third week. I think you're going to be feeling like yourself and you're going to be really happy with your new nose. And you do need to remember though that it may take a few months or even up to a year before you have your final result that you've been looking for.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: So you've decided to get some cosmetic surgery done. How do you know that your surgeon is really the right surgeon for you? We're here with Dr. Cori Agarwal. She is an associate professor of plastic surgery at University of Utah Health.

Dr. Agarwal, say I'm looking to find myself a cosmetic surgeon. What should I be looking for as a patient?

Dr. Agarwal: I think there are a number of factors. I think you want to make sure someone has good experience and that they have good results, and it's hard to do that as a consumer when you're looking at multiple websites and comparing them. I think it's very hard to tell who's actually qualified. And so we look towards board certification as something that you need to look towards and ask your doctor about.

Interviewer: I mean, the results must be kind of important in making a decision, but the actual board certification, what kinds of things should people be looking for? Is there like a certain gold stamp of approval for "These are the best surgeons"?

Dr. Agarwal: Well, it doesn't guarantee you're going to have an excellent result or an excellent surgeon, but it definitely . . . by being board certified in a recognized board, you know that these surgeons have had a basic training, a certain number of years of surgery, and graduated from an accredited medical school, and gone through safety training, and taken oral boards and written boards. It's very rigorous to be board certified in plastic surgery and board certified in facial plastic surgery.

And so you know that at least they've gone through the correct amount of training and I think you should feel much more safe. I think if you don't see that kind of board certification, it's just more of a question mark as to where they did their training and how much training they actually did.

Interviewer: We were talking a little bit before. You said that there are certain certifications that don't really mean anything. They're just kind of buzz terms. What kind of things should people be looking out for?

Dr. Agarwal: There's a board of cosmetic surgery, and that's a board that is out there and people will put it on their website and advertise it, but it's not a recognized board by the American Board of Medical Specialties, which has been certifying all the medical specialties for a hundred years and it's the one that we look for.

So the cosmetic surgery board certification doesn't hold the same weight. It doesn't have the same requirements for medical school training, for surgery training and residency, and then the testing and maintenance of sort of the safety certification afterwards.

Interviewer: That seems a little . . . I mean, as a consumer, I would see cosmetic surgery board and just assume that, you know, it's solid, that that's a real, legitimate board. Are there any particular names of organizations or something that we should be looking for, that if you see that for a surgeon, you know they're going to have that experience, that certification?

Dr. Agarwal: Yeah, I think the easiest one is the American Board of Plastic Surgery. If you are certified by the American Board of Plastic Surgery, nearly all of them will have the ASPS stamp on their website, American Society of Plastic Surgeons. So once you see that, you know for sure that they're certified.

There's also a facial plastic surgery certification that's equally good through training in otolaryngology. And so, if you see those as certifications, then you know that your surgeon has gone through appropriate training.

Interviewer: But it's not just that board certification. I mean, when you're talking about these types of results, they're something a little different than just a heart surgeon. What is it about plastic surgery, facial plastic surgery especially? What kind of relationship do you need to . . . as a consumer, how do you know that you have found the right surgeon?

Dr. Agarwal: Yeah, I think that's a really good point. I think there's something about a patient/doctor relationship, and I think you need to go in and meet your surgeon, talk to them about your goals, see if they listen to you, see if they see what you're looking for, and you seem to have a good eye to eye.

And I think one thing you can do is ask to see results. You can see before-and-after pictures that your surgeon may put on the website, or if not, then perhaps in the consultation they can show you some of their results from previous patients.

But I think it's making sure that this surgeon understands what you're looking for. They're not trying to push something on you. They're really listening to what your goals are for your desired surgery.

Interviewer: So other than asking for, say, before-and-after results and making sure that they're listening, what kinds of questions should you ask on that first consult to kind of get a feeling if they're the right doctor for you?

Dr. Agarwal: You know, I think it depends a lot on what you're looking for. So if you're looking for rejuvenation versus rhinoplasty versus eyelids, there are going to be specific questions.

I think you should do some homework and do some reading about the type of surgery. You never want to Google too much about your surgery, but I think it does give you a little insight into the terminology and, you know, make sure that the surgeon seems to understand what you're looking for.

It's important for them to talk to you about risks of the surgery. I think you have to go into any surgery knowing that there are always some risks involved. And if the surgeon doesn't bring any of those up, you may want to ask them about that.

Interviewer: So do your homework. Do your homework and go to that consult with eyes wide open.

Dr. Agarwal: You know, one other thing that can be helpful is looking at reviews online. They're not always going to be great as resources because some people just want to vent or complain, and so it's hard to know if that's all legitimate, but I think it gives you a trend.

I think if you see a lot of positive reviews, or a lot of negative reviews alternatively, that does give you some insight. You have to be careful where these sources are coming from, but it's something that I think goes along with doing your homework about a surgeon.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.