Body Contouring after Weight Loss: A Conversation Via Email

I thought that post-bariatric patients who are interested in body contouring may find this electronic conversation informative.

    

    

“Anna L.” and I got to know each other after she used the “contact us” function from my web site…

    

At this moment I'm researching costs before I book an appointment.  I would like to have a high and a low estimate for a complete body lift and breast enlargement surgery (1 cup size larger with silicone gel implants). I understand that the estimate will be very “rough” without a proper consultation.

    

Please understand that I live in Edmonton, Alberta, so even the initial consultation will entail a large cost for me due to the travel.

    

I think that excess skin will need to be removed from my abdomen, thighs, arms, back, and buttocks. A breast lift is not needed; there is no sagging there.  In addition I would like to have the muscles repaired/tightened in the abdomen. The excesses skin removal is needed due to a weight loss of 160 pounds.

    

Second, I would like to know if these procedures can be done at one time, rather than separated over weeks or months.  Please e-mail me!

    

Thank you for your time and take care,

Anna

    

    

My long-winded response (with information about body lifting, breast augmentations, pricing, and staging procedures):

Dear Anna,
    
Glad that you emailed!

    
First, I wanted to let you know that you are not alone.  Many of my patients have lost 100-300 pounds, and most are anxious to tailor their old suit of skin down to their new, svelte sizes.
    
Some rough cost estimates:
    
When I am talking about a circumferential lower body lift, I am including...

·         buttock lifts bilaterally

·         hip/outer thigh lifts bilaterally

·         pubic lift/recontouring

·         abdominoplasty/tummy tuck, with muscle tightening

·         limited liposuction of the back and "saddle bags"

    
This procedure is approximately US$15,400.  No hidden costs!  That quote includes my fee, my surgical assistant's fee, my anesthesiologist's fee, the operating room fee, a night of hospitalization, and post-operative garments.  You would additionally be responsible for travel expenses, hotel costs for the night before surgery, lodging during your recovery, costs of pre-operative exams and testings (such as chest X-ray, EKG, and blood work), and medication expenses (for pain medications, sleeping pills, antibiotics, etc.)
    
For breast enlargements with silicone gel implants, I am including...

·         my fee

·         my assistant's fee

·         the OR/hospital fee

·         the anesthesiologist's fee

·         post-operative bras

·         the cost of the implants ($900/implant in the USA = $1800)
    

This procedure is approximately US$5800.  Once again, no hidden costs. 
    
Of course, performing the two surgeries simultaneously would provide cost savings—about $1500.  The total would, therefore, be approximately US$19,700.
    
However, I generally recommend that patients NOT undergo chest and abdominal surgery simultaneously.  The circumferential lower body lift is enough surgery for most people for one day!  I would be happy to give you the names of 5-10 of my recent patients.  I have managed to talk each one out of adding breast, arm, or thigh surgery to the body lift—just too much for most people to recover from.
    
On the other hand, just last week I simultaneously did an abdominoplasty (front side only) and breast augmentations with lifts.  But this patient is only 23 years old, and she swims 1-2 miles plus bikes 20-25 miles each day!  She is in unusually good shape.
    
I would always be happy to see you in my office in California.  I wish that I could refer you to a plastic surgeon who is in your region of the continent.  However, I actually don't know any of the plastic surgeons in Alberta.  One of my good buddies is from Saskatchewan (although he now practices in the States), and I'll ask him whether he knows anyone up in your area who has a specialty interest in post-bariatric body contouring.  This is a new (and challenging) sub-specialty in plastic surgery, and so you don't want to visit just anybody; make certain that person has trained him/herself in the nuances of post-bariatric plastic surgery.
    
My best wishes to you,
Mike Pickart

    

    

Anna continues to wonder about combining procedures:

    

Greetings, Dr. Pickart,

    

Thank you for your quick response and your kind words.

    

At this point I’m willing to forego breast augmentation because this is a surgery that I can have done in Edmonton at a later time after I have recovered properly.

    

However, I have not been able to find any plastic surgeons in Canada that specialize in plastic surgery after massive weight loss, such as yourself.  If you do hear of someone I would greatly appreciate that information.

    

Now to be honest I don’t swim 1-2 miles and bike 20-25 miles a day.  But I am young (24 years old), and I am physically active. I am very healthy and strong. I do believe I can handle a full circumferential lower body lift, plus a thigh lift and an arm lift at one time. Would you be able to perform these procedures at one time for me? If not, how long would you suggest I wait to have the thigh and arm lift?  And can you please tell me the added cost of the thigh lift and arm lift?

    

Thank you and take care,

Anna

    

    

I try to explain in more depth my rationale for staging procedures and to provide information regarding pricing:

    

Dear Anna,
    
You're correct that breast augmentation surgery can probably be done anywhere.  You do NOT need to travel all the way to California for a standard breast augmentation.  Most plastic surgeons do breast implant surgery all the time, and most do it very well.
    
However, if your breasts are not only small but also "droopy" (which is the case for most weight-loss patients), then you might benefit from a lift at the same time as the placement of the breast implants.  (The technical term for a breast lift is a mastopexy.)  Combining breast augmentations with mastopexies is NOT easy surgery.  In fact, many of the leaders of North American plastic surgery state to NEVER do these procedures simultaneously.  They think this combination is just too darn hard and too unpredictable.  I emphatically disagree, but to do the surgery right takes a long, long time.  It's not a quick procedure lasting just 60-90 minutes.  I usually spend 5 hours on breast rejuvenation when combining implants and lifts.
    
As for arms and thighs, I would be willing to do arms at the same time as a circumferential lower body lift.  However, I would try to dissuade you.
    
And I would definitely NOT do the thigh lifts at the same time as the circumferential lower body lift.
    
My reasoning:
    
1)  Arms:  The arms are a separate anatomic unit from the lower body (abdomen, pubis, hips/outer thighs, buttocks, and lower back).  Hence, the surgical manipulation of one will not influence the result at the other.
    
However, most of my circumferential lower body lift patients do rely on their arms for post-operative transportation.  Many patients use a walker (or cling on to their family members), so that they can ambulate immediately post-operatively.  (Walking helps blood flow, thereby aiding healing and minimizing risks of blood clots.)  Most patients lean on their walkers with their arms and hands.  It would be very difficult to walk around after surgery without healthy upper extremities.
    
Nevertheless, I have done arms and circumferential surgeries together on a couple of occasions before, and the patients both did heal without significant issues.
    
The cost for brachioplasties is about $6900, which is all inclusive (surgeon's fee, surgical assistant's fee, anesthesiologist's fee, operating room fee, etc.).
    
    
2)  Thighs:  The inner thigh surgery and the circumferential lower body lift involve surgery on adjacent anatomic units.  Hence, the simultaneous surgical manipulation of either area will affect the surgical outcome at the other site.  The results may, therefore, be less than perfect.
      
I am not the only plastic surgeon who would caution you against simultaneous thigh and circumferential surgeries.  At the last post-bariatric-plastic-surgery meeting that I recently attended, most of us agreed that patients should wait at least 6-12 months between a circumferential lower body lift and thighplasties.  And, almost all of us are convinced that we obtain better results by doing the circumferential lower body lift first.

    
Anna, your questions are excellent and very sophisticated.  Great job on self-education!
    
Sincerely,
Mike Pickart

    

    

Then, Anna asks many practical questions:

    

Dear Dr. Pickart,

    

I really appreciate you taking time to explain why the procedures should be broken up. I also appreciate the e-mails I have received from your past patients regarding their experiences.  I agree now that it would be best to just have the circumferential lower body lift, and, once fully recovered, to have either the arm lift or inner thigh lift next.

    

I understand that, before performing surgery, you would want to have a proper consultation.  But, first, I have a whole barrage of important questions for you….

    

1)      Where will you perform this surgery?

2)      Who will perform the anesthesia?

3)      Who will be responsible for all of the postoperative care?

4)      How long will the surgery be?

5)      How long will I be in hospital?

6)      How long would you recommend I stay in Ventura before flying home?

7)      How long would you recommend I be away from work?

8)      May I look at typical before and after photos of your work?

9)      In your experience how many pounds of skin will be removed?  (I’m currently 20 pounds away from my ideal weight for my height according to BMI charts)

10)  How long will it be before I see the “best” results from the surgery?

11)  If I’m unhappy with the results, what is your policy on surgical revisions?

12)  What permanent scaring can I expect?

13)  Can these types of scars be removed via laser treatments?

14)  What are the risks?

15)  And what, if anything, can I do to minimize the risks?

    

Thank you and take care,

Anna

    

    

My answers to her great questions:

    

Dear Anna,
    
First, I'm cc'ing my practice manager (Sharon Marshall, info@coastalskincare.net) on this email so that she can work with you regarding timing.
    
Second, if you could send me some personal photos, they would be helpful.  (Nudes are preferable; bathing suit at the minimum.  Use bright, "unforgiving" lighting.  Take some photos of the front, at 45 degrees, at 90 degrees/sides, of the back/buttocks, etc.)  I could then do a "virtual" consultation electronically.  At least then I could reassure you that the plan is sound.
    
Third, some answers to your (good) questions:
    
    
Where will you perform this surgery?
    
St. John's Regional Medical Center, in Oxnard, California.  This is a fully accredited, community hospital with an outstanding local reputation.  SJRMC's bariatric program is the busiest in Ventura County, and is probably busier than all of the programs in LA County except for UCLA.
    
    
Who will perform the anesthesia?
    
A Board-Certified Anesthesiologist.  I use physician anesthesiologist only—and only those who have passed all exams.

    

    
Who will be responsible for all of the postoperative care?  How long will the surgery be? How long will I be in hospital?
    
I am responsible for everything.  I will see you in the hospital before, during, and after surgery.  I give my cell phone number out to all of my patients.  If there is a problem, they call me directly—not a nursing line, an intern, or a resident.
    
The surgery itself takes 8-9 hours.  But the whole process is actually 36-hours long...
    

·         The night before surgery, meet me at my office for 1-hour of markings, discussion, question-answer, etc.

·         The day of surgery, you arrive at SJRMC between 5:30 am and 6 am.

·         I arrive at about 7 am.

·         Surgery starts at 7:30 am or 8 am, and lasts until 4 or 5 pm. (I leave for 5 minutes to drink a soda, eat half a sandwich, and use the bathroom.  Otherwise, I never leave!)

·         I speak with your family/friends at 5 pm (although I make certain that they are updated 3-4 times throughout the day via phone calls).

·         I call you at 8 pm, just to check up.

·         I see you at 7 am the following morning.

·         Most patients leave later in the day.

·         You may certainly stay an additional night at SJRMC.  You will have your own room, with your own bathroom, your own TV, etc.  However, hospitals can be expensive—$855/night.

    

    

How long would you recommend I stay in Ventura before flying home?

    

At least 10-14 days.

    

Complications are the norm for circumferential lower body lifts; the complication rate is about 60%.  (However, most of the complications are minor.)  In the past 2 months, I have performed 3 body lifts, and 2 patients had complications that necessitated additional visits to my office:

    

1)      The first went absolutely perfectly.

2)      The second patient suffered an infection that required oral antibiotics.

3)      The third suffered partial death of her belly button.

    

All three eventually healed fine, and all three are thrilled, but I never deceive patients about potentialities.

    

Regardless, most complications rear their ugly heads within the first two weeks.  If you can stick around for at least that long, I would appreciate it.

    

Nevertheless, it wouldn't be a bad idea for you to develop some sort of relationship with a local plastic surgeon—just in case something happens after you return home.  Ask him or her, "Since you will be performing my breast augmentation within 12-18 months, can you help me out—if I need it—after I return from my circumferential lower body lift?"  Also, a local plastic surgeon will be absolutely invaluable for your drains....

    

I usually leave 4 drains in place after circumferential lower body lifts.  I can usually remove the first within 4-5 days.  The second and third usually come out within 10-14 days.  However, the last one may require 3-4 weeks.  Patient #3 had her last drain for 5-6 weeks.  Drains come out when they produce less than 30-40 ml/day—whenever that happens to be.

    

    

How long would you recommend I be away from work?

    

What do you do for work?  If you are someone who does a lot of physical labor, I'd recommend...6 weeks.

    

However, if your work mostly requires that you use just your brain and your fingers, I'd recommend...2-3 weeks.

    

None of the three aforementioned patients are physical laborers.

    

1)      Patient #1, who is 52 years old, was back to work in 2 1/2 weeks.

2)      Patient #2, who is 45 years old, 2 1/2 weeks.

3)      Patient #3, who is 60 years old, 5 weeks.

    

    

May I look at typical before and after photos of your work?

    

Check out my website at www.pickartplasticsurgery.com.  I can also send you images directly.  Please delete these photos after you have viewed them.  These patients have been very generous to allow me to show their pictures to other patients; I would not want their photos to end up on the internet for everyone to see.

    

    

In your experience how many pounds of skin will be removed?  (I’m currently 20 pounds away from my ideal weight for my height according to BMI charts.)

      

Anywhere from 5 to 15 pounds.  Some examples,...

    

1)      Patient #1 (261 lbs. to 112 lbs. after laparoscopic gastric bypass):  5 additional pounds removed from the circumferential lower body lift.

    

2)      Patient #2 (260 lbs. to 160 lbs. after laparoscopic band):  12 pounds of skin from the circumferential lower body lift.

    

3)      Patient #3 (426 lbs. to 180 lbs. after laparoscopic band):  14 pounds of skin from the circumferential lower body lift.

    

    

How long will it be before I see the “best” results from the surgery?

    

Tricky question!  I'm going to say...within 1-2 months.

    

·         Most patients are very happy immediately.

·         Swelling, however, persists for 6-8 weeks.

·         And final scar maturation/collagen remodeling does not occur for 6-12 months.

    

Most patients, however, can start buying new clothes within a month or two.

    

    

If I’m unhappy with the results, what is your policy on surgical revisions?

    

Fortunately, this issue does not come up that often.

    

Usually, the patient and I decide what caused the problem.  For example, if one of the stitches "popped," then I consider it a surgical issue, and I do not charge a surgeon's fee.  However, if a patient's post-operative contour is sub-optimal because her weight fluctuated or because her skin was of poor quality, I consider these patient issues, and I do charge a surgeon's fee.  (To be honest, I am a softy.  I almost never charge additionally.  The hospital, nurses, anesthesiologists, etc., on the other hand, are not always so soft.)

    

    

What permanent scaring can I expect? Can these types of scars be removed via laser treatments?

    

There will be a circular scar that travels all the way around your lower torso:  between your belly and your pubis, toward either hip bone, around both sides, and above both buttocks.  There will be a second, diamond-shaped scar around your belly button.

    

Lasers are useful to minimize the redness of scars.  However, lasers do NOT erase scars.  The scars will usually fade with good routine scar care, but the scars will be permanent.  Even a plastic surgeon's scars will be visible if you look for them.

    

I usually refer about 5% of patients for post-operative laser treatments.  It is the rare patient who complains about my scars.  (However, some patients of African or Southeast Asian descent tend to scar poorly (with "keloids") and these patients do require special management.)

    

    

What are the risks? And what, if anything, can I do to minimize the risks?

    

Risks:

    

·         Infection (<5%--even with modern antibiotics)

·         Wound healing problems/wound formation (30-40%—usually in patients who remain significantly overweight)

·         Bleeding/blood accumulations (<5%)

·         Other fluid accumulations (known as seromas) (<5%)

·         Asymmetry (100%—everybody starts out asymmetric!)

·         Unsatisfactory cosmetic appearance (<5%)

·         Deep venous thrombosis (DVT) (Blood clots in the deep veins of the legs) (5%)

·         Heart or lung problems (2-3%)

    

To minimize the risks, be healthy!  High-protein, low-fat diet.  Lots of exercise.  No smoking.  No recreational drugs.

    

Also, avoid aspirin, Advil, ibuprofen, etc. for 10 days before and after surgery.  These medications are potent blood thinners.  Tylenol, however, is not; so, if you have a headache during the week before surgery, then use Tylenol.

    

Phew!  Lots of writing.  Hope this all helps!

    

Sincerely,

Mike Pickart

    

    

Anna wonders about sequencing her arms and breasts relative to her torso and she considers adding a little liposuction to the circumferential lower body lift:

    

Hello again, Dr. Pickart,

      

Thank you for your responses and for the pictures.

    

I started to examine other areas of my body, and I realized that I do have a significant amount of excess skin on my upper body as well (back, sides and front).  I was wondering if these areas can be addressed as well.

    

Second, I'm also considering having an arm lift and possible breast augmentation (or just an arm lift) at least 2-3 months before the body lift.  Is this time enough for full recovery before the body lift? Would you advise against this? Would it cause issues with the results of the lower body lift and any work that may be done to the upper body?

    

I also would also be willing to have liposuction if needed. As I have stated earlier, I'm 20 pounds away from my ideal weight (having dropped from 318 pounds to 158 pounds).  I guess it would be difficult to say how much of that 20 pounds is extra skin and what is just extra fat. I do desire to have a "slim" figure. With the pictures I'm sending I would like to know if I can have that desired figure.

    

Take care,

Anna

    

    

I explain to Anna about near-circumferential upper body lifting, which is a powerful (albeit uncommonly performed) technique for upper torso rejuvation:

    

Dear Anna,
    
In addition to circumferential lower body lifts, a minority of my weight loss patients benefit from "near-circumferential upper body lifts."  These all-the-way-around operations serve different purposes:
    
Circumferential lower body lifts:

·         Pubis

·         Belly

·         Umbilicus

·         Sides

·         Hips

·         Saddlebags

·         Buttocks

·         Lower back

    
Near-circumferential upper body lifts (near-circumferential because the incisions on the right and left rarely meet in the middle in the front—across the sternum/breast bone):

·         The lateral/armpit portion of a breast lift

·         Armpits

·         Upper flanks

·         Upper back

    
I usually prefer to do the lower body lift first.  The lower lift sets the tension for the breast lift and upper body lift.  Moreover, some patients who thought that they would require both upper and lower body lifts actually only require the lower after the appropriate smoothing/tightening is performed on the lower torso.
    
I usually perform the upper body lifts in conjunction with arm lifts and breast lifts.  These procedures share incisions, and so it is least traumatic to operate on these areas only one time.
    
With regards to your last 20 pounds, I wouldn't be surprised if body lift surgery, brachioplasties, thigh surgeries, and liposuction could bring you down another 10-20 pounds.  Don't starve yourself before plastic surgery!  You'll need good nutrition to heal properly.  As always, a diet with little fat and a lot of lean protein is always best.  Lots of fruits and veggies are also good for you.
    
Looking forward to the photos,
Mike Pickart

    

    

Anna sends her photos [but I have deleted them from this publication of our electronic conversation in order to respect Anna’s request for privacy]:

    

Hello again, Dr. Pickart,

    

My pictures are attached to this e-mail. I have been thinking back to your last e-mail; you said that you were looking forward to these photos.  Boy, that made me laugh! I can't believe you would be looking forward to seeing them—they’re not pretty. LOL. So, I offer my apologies. :)

    

I'm also attaching pictures of the areas of my upper body that require attention. Hopefully, you can give me some idea of what would be needed and a price estimate for the upper body.

    

In the end, I would like to have all these procedures done with you. After my lower body lift, I would like to proceed with the upper body work, including the arm lift and perhaps breast augmentation.  The third procedure would be for my inner thighs.

    

Thanks again for your time, and take care,

Anna

    

    

My assessment of Anna’s photos:

    

Dear Anna,
    
You are just like all of my other patients—your own worst critic!  Are you kidding?  You look great!  Sure, there is some extra skin that I can help with, but I can tell that you are fit.  If I haven't done so before, let me congratulate you on your 160 pounds of weight loss and on your return to health.
    

Based upon your photos, I agree that you would achieve a tremendous result from a circumferential lower body lift....
    

·         Although I cannot see your pubic region directly, there appears to be some fullness that would benefit from reduction, elevation, and lateralization (thereby making the pubic area smaller, higher, and flatter).

·         Your belly exhibits a vertically excessive "apron" that could be removed, while tightening the abdominal muscles (the "six pack") and reconfiguring the bellybutton.  The "crease" between the two sides of the "apron" is typically asymmetric; this should present no problem when I create a smooth, firm, flat tummy.

·         Although I can see only your left flank and hips (which are partially obscured by your undergarments) (and I don't have photos of the right side at all), it seems that there is laxity on your sides that extends from your outer thighs up to your mid torso.  The lateral/outer portion of the circumferential lower body lift will almost certainly benefit this region with some of the additional pull translated down your outer thighs.

·         The buttocks seem full, rather than flat.  Simply lifting the buttocks would provide an appropriate shape and would smooth any dimpling.

·         The "rolls" at the back may be tricky.  Frequently, lower body lifts are great at lifting the buttocks or at getting rid of back rolls, but cannot always accomplish both goals.  You and I may need to make a decision as to which of the two issues bother you more, and then I design the surgery to emphasize the greater correction of one at the expense of the other.  Make sense?

·         Nevertheless, recently, I have purchased an ultrasound machine which I use in conjunction with traditional liposuction to optimize back fat removal and to minimize rolls.  Although I can never make firm promises, this new ultrasound technology (called VASER liposelection) may enable me to get at your back fat without the need for additional procedures.  (Translation:  No upper body lift?!  Please read on.)
    

As for your arms, longitudinal brachioplasties extending from your mid-arm (between your elbow and armpit), to your armpit, and then down along your chest wall may be all you'll need.  Without seeing photos of your breasts and of your back without the bra, I cannot be sure, but I don't think that you need a near-circumferential upper body lift (especially since I will use the VASER to remove the back fat/rolls).  Let's not plan on an upper body lift for now.  Instead, let's see what kind of a result we can achieve with a circumferential lower body lift that is combined with vigorous ultrasonic liposuction.
      
As for your thighs, I do see some laxity to the skin but you may not need longitudinal incisions.  (Translation:  The incision may not need to extend from your groin all the way down to your knees.)  I may be able to limit the incision to the groin area alone.  Certainly, the result is not nearly so dramatic when the scars are limited.  Before I make any promises, I'd better see your thighs in person.  I guess that we'll know each other very well, before we finally commence the thighplasties!
    
I will Cc this note to my practice manager (Sharon Marshall, info@coastalskincare.net) so that she can provide pricing information regarding...

·         Circumferential lower body lift

·         Brachioplasties

·         Breast augmentations (with silicone implants) (You don't think that you need breast lifts, do you?)

·         Inner thighplasties

    
Best wishes,
Mike Pickart

    

    

Anna expresses why she is undertaking this journey, and she summarizes her plan:

    

Greetings, Dr. Pickart,

    

Thank you for your prompt email. Also, thank you for the congratulations and for your kind words.

    

It’s funny.  I look great with my clothes on, because I use a corset to hold the “extras” in. I feel great when I see myself in shop windows, but, then I think of what’s underneath, I’m not so happy anymore.  I do know that I’ve come along way.  My health was most important when I began my weight loss journey.  But, now, as I girl about to be twenty-five, certainly the way I look can be just as important.

    

I apologize for no nude shots. I understand now why those were important; however, I was too bashful to stand naked in front of my photographer.  Of course, when we do meet, you will be able to give me a complete assessment.  As for the lower body lift do you need additional photos from me or do you think these are fine for the time being?

    

I’m excited at the possibility of no upper body lift, but I’m prepared if I do need one. I would love to have my breasts done; however, cost is a factor.  If I feel I can afford it, I will have them done with the arms and upper body work. The inner thighs, arms, and thighs are more important to me than my breasts. At this moment a C-cup push-up bra is giving me my desired look!  I have lost volume in my breasts, but I have maintained my B-cup size. (And I’ve never had the pendulous breasts that most obese people have.) There isn’t any significant breast sagging.  As for the making a choice between a better look between my buttocks and lower back, I definitely choose the rolls on my back.

    

And thank you so much for the detailed information.  It is greatly appreciated.

      

I’ll contact Sharon soon.  I want to have the lower body lift within a couple of months, and then the arms, upper body and possibly the breasts done as soon as possible after the lower body lift.

    

Take care,

Anna

      

    

I finalize our plan:

    

Dear Anna,
    
For now, I think that the current photo set is adequate.  I will definitely obtain a set of my own (full nudes, of course) for my pre-operative planning and for documentation of the "before."
    
So begins the customization of your first stage—the circumferential lower body lift:

·         focus on the lower back rolls rather than the buttocks

·         focus on tightening the flanks and lifting the hips/outer thighs

·         focus on a flat tummy with rejuvenated belly button

·         focus on restoring the muscles into a tight "six pack"

·         focus on reducing, lifting, and flattening the pubic area

·         add ultrasonic liposuction to smooth the upper back (and to, hopefully, avoid the need for an upper body lift)

    
Next stage—arms and/or upper body and/or breasts.
    
Final stage—thighs.
    
Anna, if I didn't mention it before, the recovery from any one of these procedures is difficult.  Most patients would agree that even routine breast augmentation hurt a fair amount for a couple of days.
    
I know that you have done your research, and you are approaching plastic surgery with a lot of knowledge.  That's great!  But please don't expect too much of yourself.  Most of my patients want all of the procedures done ASAP.  However, after the first (usually the circumferential lower body lift), most do prefer to wait more than the minimum amount of time (3 months) until the next stage.  It takes a lot of energy to recover from big plastic surgery procedures; the reality is somewhat different than what you see on TV!  Pace yourself, and give yourself plenty of time to recover between stages.
    
Best wishes,
Mike Pickart