My High BMI Panniculectomy Journey

Part Two: Consultation Appointment

I had high hopes for the appointment with the first general surgeon. I had verbally given my surgical and weight history to the nurse and she replied that the doctor said, “Congratulations on your significant weight loss! We can see you for a panniculectomy at your current weight to discuss it.” YES! So excited and so anxious!

But as I got more details closer to the date, I realized the appointment was likely to tank. The consult was scheduled for only 15 minutes in-person and included a mandatory bare-skin exam. I spoke with the nurse several times, pleading for a longer appointment, and to postpone the exam portion till a second appointment. This was firmly denied as a possibility until I was in the car on the way to the appointment. I had childcare so I could not reschedule.

When I got there, the surgeon walked into the appointment and stated that I was not far enough out from my revision for a panni. They were also irritated that I did not reschedule with their “generous” offer of a longer appointment a month from then. Immediately after that, they wanted me to show them my skin for evaluation which I declined as I needed more time to build rapport and safety. Their body language became even more defensive.

When I explained that I was regularly stalling, they told me I needed to eat less as “clearly [I was] eating too much.” I could come back when I reached 9 months post-op and they wanted me closer to a 40-45 BMI. Um, that was my goal weight and there was no way that I would get there with this mass of skin and fat!

I left the appointment and proceeded to weep in my car. I don’t remember how I made it home, but thankfully it was not a long drive. I already had a second consult set up for the next a week after that but I was so shaken by the miscommunications and dashed hopes that I called his nurse the next morning. I begged for any option possible to be able to get a message to the doctor in my words. She allowed me to email her something to give to him.

A small snake, peering curiously straight into your soul–the perfect depiction of how I arrived for my 2nd consultation. Taken at Calvin University’s Ecosystem Preserve by Bill Vriesema

Well, he read the email. He signed on to the video appointment on April 13, 2021, visibly pensive with a slightly furrowed brow. He jumped right into talking about the risks as the email provided my history and purpose for seeking one at 377lbs. But right off the bat, I felt heard. I felt seen—my struggles, my determination, my fear of failing.

His words were honest and vulnerable—not common traits in an experienced surgeon. I could feel his unease and uncertainty from 43 miles away. I don’t think I was breathing much. I was furiously writing down all the risks as he described in great detail what was likely to happen, and it was grim. The heaviness of this appointment seemed to be affecting both of us.

He told me, “I can do this surgery, but I don’t want to put my name on it. You will NOT look okay. You’ll have dog ears, more hanging skin as you lose weight, and you’ll likely be re-hospitalized with wound complications. I also don’t want to make the body dysmorphia you mentioned worse. I can’t say it enough. You will not look okay if I do this surgery now. Knowing all that, do you still want to do this?”

I started to cry. I answered, “Yes, I think this is what is holding me back from meeting my health goals.” He quickly asked me how I felt about blood transfusions and said the chances of needing one were high. “I won’t force you to have one but for safety, I cannot do this surgery if you’re not comfortable with having one.” I awkwardly choked out the words, “Yes, all life-saving measures! I am doing this in hopes to live, not to die!”

And with that, his relief was evident. He asked if I was comfortable standing up to show him my skin and I was. I felt safe enough to even pull my pannus out of my pants to show him better how far it hung! That is a feat no other doctor has ever accomplished before then. I didn’t feel judged at all. I know the physical distance of the virtual appointment helped greatly with my comfort.

He said to get off as much weight as possible before the surgery but he wasn’t going to require a specific amount. That relieved a lot of stress and prevented me from the pitfalls of perfection and past failure overshadowing my drive. We wrapped up the appointment and set a date for 2 weeks from then for the physical in-person exam.

(Part 3 coming!)

My High BMI Panniculectomy Journey

Part One: Finding a Surgeon

It took a year to write this.

Why?

Because the public, social media, and many medical providers have a variety of negative opinions and think it’s absolutely foolish and dangerous to have a panniculectomy if you’re fat.

Many people will look at the pictures and criticize me for having surgery before I met “goal weight” or a desirable BMI for a plastic surgeon. They may say that the surgical result looks terrible and think the surgeon did a poor job. Judgment and ignorance abound. Let me enlighten you.

This was an extremely emotional journey that came after several years of fighting for appropriate medical care. I was repeatedly turned away from the best medical solutions based solely on my weight. The battles endured to attain those surgeries drained me, but as my body and mind healed, my fire came back.

While attending an Unjury Cares Support Group for bariatric surgery, they talked about skin removal. I was only a few months post-bariatric revison surgery but I am one of those “research everything extensively, prepare, and act” kind of people so thus this all began.

Mackinac Bridge: the world’s longest suspension bridge by length located in Michigan. Reminds me of the length of my journey. Photo courtesy of Bill Vriesma

I started calling providers in-network to find out their surgical criteria. Most would not even do a consult for a future procedure unless I had a BMI of 30 or less. That’s pretty discouraging to hear when your highest BMI was 82.7 and you fought really hard to lose over 130lbs at the time of the calls.

Some offices were polite and sympathetic to my disappointment. Others were downright cruel with their responses. I hung up in tears with each call with my first bariatric surgeon’s voice in my head: “No one will EVER do a panniculectomy on someone over a BMI of 30.” That sentence damaged my confidence in ever being successful with weight loss surgery from a mental health and body dysmorphia standpoint.

But I was 22 then: naive, believing that one doctor’s word was law. I now know that to be untrue. Some bariatric offices across the world do panniculectomies on people at my former size in combination with their stomach surgery. Then after their weight loss is more successful in large part due to the panniculectomy, they have a revisional surgery at their goal weight.

I soldiered on armed with a mask of self-confidence that I knew what I knew and there may be a surgeon willing to LISTEN to what I was asking. All I was hoping for was a conversation. I just needed to know from a provider what criteria I had to meet to be eligible. After being rejected by 6 offices across the state of WI, I finally found 3 surgeons willing to have that conversation.

Cue panic attacks, self-doubt, and medical trauma triggers.

(Check out Part Two!)

This video shows my journey from 2018-2022. It does include a non-gory picture of the surgical incision that may still be too much for those with vivid imaginations. There is a video without on my Tik Tok account labeled “No Surgical Incision Version”.

Why “Wisconsinite Yooper?”

So, hey, this is a blog about medical self-advocacy, neurodivergence, and trauma stuff, but the name doesn’t match up… You’re over there scratching your head so I will fill you in on “why.”

Many people know what a Wisconsinite is but “Yooper” – well, that’s a term unknown to most. A Yooper lives in the UP: The Upper Peninsula of Michigan—Wisconsin’s unwanted neighbor. 

Map of the State of Wisconsin with the Upper Peninsula of Michigan

A Yooper speaks similarly to Canadians on the Red Green TV show, eats pasties, and has a steady diet of venison to go with WI beer and cheese curds. Buried in thick national forests and snow-covered for nearly 9 months a year, it makes sense that the region is populated mostly by Indigenous Tribes, Finns, and Swedes. You have to be pretty resourceful and resilient up there!

Into this Midwestern gem, I was born. I spent my early years in Northern Wisconsin on Chequamegon Bay and moved to the UP halfway through my childhood. I found my way back to my WI roots to raise a family but the Yooper is a foundational part of my being. I mean, trudging through several feet of snow in negative degree temps to deliver newspapers while icicles form on your eyelashes IS going to make you a stronger person!

Zjanee on her paper route, age 12, in Bessemer, MI. Courtesy of Samantha Zweber

The beautiful parts of my childhood include swimming in the vast, chilly Lake Superior with horse flies targeting any skin left above water, iron ore-stained shoes and bell bottoms, waving to everyone who walked or drove past, and mischief with my sisters. 

But living that isolated brings challenges. Bars are as numerous as churches. People commute long distances for higher-paying jobs. Under-employment is rampant. Abandoned houses become meth operations. Social services are poorly funded. Specialty health care is often months out & a 2+ hour drive one way so—heaven forbid—you finally snag an appointment and a snowpocalypse hits… You do NOT cancel!

Zjanee’s UP childhood home with snowbanks higher than the entrance doorway. March 24, 2014. Courtesy of Samantha Zweber

From these hardships, Yoopers honed stubborn determination and self-reliance. You’re on your own for most things due in large part to the economic depression as logging and mining dwindle. UP communities are creative and everyone does what they are able. For example, when I lived in Ewen, MI, the volunteer first responder was a disabled man with a bicycle and a reflective vest. He kept people safe from downed power lines and did basic first aid until an ambulance arrived from an hour away.

So now you know what a Yooper is. But maybe you’re still asking why I chose this obscure name for the blog. Well, it’s because growing up here with this collection of experiences molded me into the person I am now. Obviously, my neurodivergent brain and perception impacted that, too, but I can’t see myself being the same wife, mother, friend, or advocate without the direct influence of life in Northern Wisconsin and the Upper Peninsula. 

Say ya to da UP, eh!

Vulnerability with Medical Providers

Being vulnerable with anyone is daunting. Add in trauma and power dynamics within doctor-patient relationships and you’re looking at a potential triggering situation that can throw you into a mental and physical health flare. Balancing the risks vs. benefits of seeking care can be utterly anxiety-provoking.

Last week I had to face the reality that I still trigger immensely when I am under stress. I needed to get examined for possible hernias. When triggered, any touching or visual inspection of my knees to the top of my cleavage is a HARD PASS.

Currently, the only provider I am comfortable with doing that is my PT who does lipedema and scar tissue massage for me. It took hours spread over several appointments with talking, no touching, and her earning my trust by accommodating my needs for me to trust her. This issue couldn’t wait for that rapport to be built with a general surgeon.

Thankfully, my husband was also seeing a general surgeon. He was incredibly accommodating to our family’s needs for scheduling and appointment location (the initial consult was virtual which is uncommon for surgical needs), and he did not dismiss my husband’s symptoms even though they were atypical. He squeezed me in last minute staying after his shift ended.

Three mushrooms on a tree trunk in Ironwood, MI. Photo courtesy of Samantha Zweber

Prior to scheduling and my arrival, I spent a large amount of time talking to the nurses for my PCP, the surgeon’s nurse, and the schedulers for both departments about my trauma and sensory triggers being in full-blown panic mode. Both places assured me that my wish to not be touched or exposed would be honored.

When I arrived at the appointment, I was actually experiencing significant pain along with the triggers. The nurse and surgeon were not thrown by my request to address my husband’s needs first though they wanted to start with me as they could see I was not well. (I normally can mask my pain and issues well enough that it doesn’t attract attention.) Graciously, they took care of him first with no more than a nod of acceptance at my curt, breathless redirection away from me.

By the time it was my turn, my pain had reduced to a point that I could talk. I was in dragon mode. I still did not want to be touched. The surgeon suggested imaging and then, if needed, the hands-on exam. He was attentive and patient. I knew it was late, but instead of going into a fawn trauma response trying to meet his needs by ending the appointment so he could go home, I stayed present.

I told him that I needed to talk out loud to process and talk through my trauma trigger. He just sat there patiently and nodded. Also of great importance, his body language and aura were giving off safety and calm.

Lichen and mushrooms on a tree trunk in Ironwood, MI. Photo courtesy of Samantha Zweber

I started talking: “My triggered side is very activated. I feel so sick right now from the pain with nausea—that’s the main pain presentation from my neurodivergence—and I don’t want to make it worse. I need to be functional after. I am worried about judgment due to my weight and that my symptoms will be discounted. It has happened many times and it is so hurtful.

“However…

“My rational side has watched how you have treated my husband even though his issues are not ‘normal’ and easy to pinpoint. You also make my body feel safe. I also know you stayed late just to squeeze me in. I can tell that you care and that says a lot about your empathy. So, since I am symptomatic right now, is there a medical benefit for you to do the hands-on examination right now?”

He said yes and reminded me that I described the bulges as “transient” so if I didn’t want to do it during the appointment, I could call to schedule during a time when they are visible again. Ding, ding, ding! Green flag to my trauma brain! He gave me control over my medical decisions. That was the last thing I needed to be vulnerable enough to expose my abdomen and have him kneel before my belly as I stood so he could feel around.

Large, half-moon mushroom on a log in Ironwood, MI. Photo courtesy of Samantha Zweber

By being honest with myself and the entire care team before, during, and after, I walked away from the appointment without adding more trauma to process in therapy. I was able to receive the best that each person could offer me because I was vocal and explicit in my requests (though I repeated things due to my anxiety and ND).

Sure, I used up more time than most patients need, but I NEEDED that time. I deserved that excellent level of medical care. I could tell they all wanted to help me and I allowed myself to receive it by using coping skills. The providers all were able to add healing experiences instead of medical trauma.

Speak up for yourself. Check your anxious thoughts. The brain and nervous system are quick to find patterns of previous threats but you need to evaluate and sort through if that is true for the present moment. And most importantly, to be vulnerable with providers, you need to trust your intuition. Sometimes the provider is not the right one and sometimes YOU are the one that is not ready to receive. Honor whatever is happening at that moment and it will have the best outcome possible.

Belligerent Patient or Neurodivergent?

Understanding Why Patients are Difficult

Providers: this one’s more geared towards you. For the Dragon patients reading, you will probably relate to much of this, or maybe some light bulbs will go off to investigate further.

Have you noticed that there are some patients that you struggle to connect with and provide care? They come into the office full of anxious questions, prickly with demands, or shut down. They may be rude to your support staff or flakey with coming in for appointments. “Non-compliant” and other code words to signal a difficult patient pepper their medical records.

Well, maybe that patient is dealing with sensory overload from beeping machines or used up all their energy trying to prepare for the appointment. Now they have nothing left for regulation, flexible thinking, or communication. It can create a terrible situation for both of you.

Heart-shaped cacti at Matthaei Botanical Gardens in Ann Arbor, MI.
Photo courtesy of Bill Vriesma

The biggest challenge that I found being a patient with these issues myself is that I wasn’t aware of them. The doctors weren’t aware of them, and at the end of the day, I was not able to receive the care that my providers were trying to offer. It just became a battle zone and I regretted going to the doctor even more.

Healthcare providers are already aware of this. However—speaking as a former social worker–when we move from textbooks into actual practice where we are burnt out, tired, and under-supported, recognizing a person’s neurodivergence or trauma can be easy to miss. Add in gender biases in research, and a lot of people are either misdiagnosed or undiagnosed!

So it’s really important that patients learn about themselves and figure out where they sit on the spectrum of neuro processing. They need to explore if mental health issues are causing dysregulation with their ability to communicate or receive from other people, explore if they are dealing with trauma, or both. All these things significantly affect how interactions with medical providers are going to play out.

Two heart-shaped cacti at Matthaei Botanical Gardens in Ann Arbor, MI.
Photo courtesy of Bill Vriesma

Managing those interactions becomes a blame game. Dragon patients want doctors to do better. Providers expect a certain level of respect and cooperation from patients. It needs to be a mutual effort. Some of the doctors/nurses/receptionists that saw my dysregulated trauma and neurodivergent (ND) side did not have good interactions with me. Other providers saw a totally different person in their office. Trauma-informed care techniques reduced my triggers and these things work well for many other ND patients. Acknowledging the impact of a Dragon’s trauma helps them move through it even if they have not begun formal treatment.

The ones who did well had these things in common:

  • Offered longer appointments
  • Accommodated virtual appointments
  • Listened with curiosity
  • Welcomed MY input on MY body and experience
  • Allotted extra time for phone calls when I called with questions
  • Provided detailed responses and some even wrote the care plan out for me to take home
  • Expressed how they were feeling that day with authenticity – very important if the provider is having a bad day!!!
  • Verbally told me I did not have to do XYZ and emphasized that it would not harm my working relationship with them to decline it
  • Offered alternatives
  • Requested time to find solutions for challenging things
  • **They were true to themselves, their comfort level with requests and they communicated vulnerably with me**

I will discuss these things further in future blogs but I want to give providers things to implement in practice, and for Dragons to be inspired to discover and request accommodations to have better appointments. When an interaction goes well, not only is medical care provided and received, but the Dragon transforms from a draining force to a collaborative patient. 

Picking a Provider

My cousin, Coty, gave me the best advice when I was starting this scary venture of helping others with their trauma triggers and medical advocacy and he was beginning a new one of his own. His advice is in my head every time I am being referred to a new specialist or looking for one on my own. He told me this:

“Anyone who answers a smart question with a dumb answer isn’t my customer.”

Insert “provider” for the word “customer” and: wow! That is a game changer with energy use, expectations and moving forward with a plan of care. Whether you have chronic or rare illnesses or more common medical concerns, remember this advice. If you encounter a provider that you don’t feel totally comfortable with, you are unsure of their expertise in meeting your medical and/or emotional needs when it comes to your care, they are not the provider for you. It is as simple as that!

White and yellow daffodil in Ironwood, MI. Photo courtesy of Samantha Zweber

Now, I acknowledge that FINDING a provider in the first place that takes your insurance, knowledgeable about your condition and is in an accessible location is sometimes nearly impossible. That is another blog entirely, but for the times you are not facing these challenges, fire the provider and move on.

My lovely friend, Raheeq, was the first person to ever teach me about standing up for my needs in the doctor’s office. She was from Kuwait and she told my husband and I that she didn’t understand why Americans didn’t fire their doctors. “Americans put up with too much from doctors. They are providing a service to the patient and the patient has more control than they realize.”

Purple and white crocus in Ironwood, MI. Photo courtesy of Samantha Zweber

Those powerful words prompted me to go on an emotional journey to find an OBGYN that was not fat biased and willing to investigate why I was having miscarriages. It was not an easy journey emotionally. One doctor even fired me as a patient—which was a valuable lesson in compatibility in itself. The outcome of a long story is 2 gorgeous kiddos and connecting with amazing providers who actually asked me to share my self-advocacy experience at a medical convention about 6 weeks after I gave birth!

Not every doctor is the right doctor for your situation. If you don’t have confidence in them, exercise your power to seek care elsewhere. It might be terrifying to say, “thanks but no thanks,” to a doctor—even more so if you are not sure what will happen afterwards, but trust your knowledge, intuition and respectfully decline their services. You can open doors for better care when you exercise control over who you allow to be part of your care team.

Beginning with Thankfulness

Sometimes in life we encounter hardship and trauma over and over. We develop dysregulation and coping mechanisms to protect ourselves that often push others away only furthering the hurt.

But sometimes in life, we also come across those who give of themselves and reach into our dysfunctional, pain filled lives and give us a balm to our wounds; they stitch up our bleeding wounds when we’ve given up on ourselves because we couldn’t hold the weight of the trauma and judgements any longer. They save us.

The doctors, nurses, schedulers, insurance agents, patient experience personnel and many others in the medical field that have taken the time to truly hear my pain and offer collaboration to meet my needs within the system they work have absolutely been a major part of my healing journey.

They have given of their emotions, sacrificed their time, accommodated what they could – in both big and small ways – and who have made me feel safe, respected and they’ve seen past my sometimes abrasive, anxious behavior: they are the reason I am alive. They are the drive behind my passion to help friends and family navigate the daunting medical system.

Bleeding hearts. Courtesy of Bill Vriesma

Being neurodivergent and having a very high level of trauma make even situations without power dynamics triggering. For me, my interactions are compounded by having a larger body making navigating this system more strenuous and biased.

I know for certain without the surgeons, PCPs, nurses, therapists, etc. that have invested in my wellbeing, I wouldn’t have the spoons left to re-engage with the system. I would not be able to invest hours in advocacy and research to get where I am today. I am eternally grateful for everything. They are the best parts of the medical system.

I want to share my experiences – both successes and flubs—to inspire, encourage and collaborate with those who want to be healers and activists in their own stories. We can change the system and reduce the trauma one interaction at a time.