More than one third of the US population suffers from obesity. Bariatric surgery (weight loss surgery) has become popular in patients with high body mass indexes. Weight loss procedures commonly involve gastric banding (lap band), gastric sleeve, or gastric bypass surgery. Some overweight patients become motivated to loose weight without surgery, embracing a healthy diet and regular exercise over time to achieve massive weight loss.
Significant weight loss (50-100 lbs or more), results in skin redundancy. A history of obesity stretches skin and causes stretch marks, signifying the loss of skin elasticity. When underlying fat is lost, the skin envelope becomes loose and saggy to various degrees. One of the most frustrating aspects about significant weight loss is that patients who have put forth great efforts to loose weight are physically unable to tighten up the skin with ongoing diet and exercise. That’s where plastic surgery comes in…
There is no reliable way to tighten large amounts of skin with anything short of plastic surgery. Basically, the extra skin needs to be removed and tightened. With the surgical removal of skin, scars will result, but they are placed to hide within natural anatomic folds and thus the boundaries of most underwear styles. Scars are permanent and everyone heals differently. Scars are initially quite visible, but with time the scars fade and blend well with surrounding skin and often look no different than a stretch mark.
The most common procedure performed for both men and women after significant weight loss and final weight stability is abdominoplasty, or “tummy tuck” surgery. In patients with a very large amount of overhanging skin and residual fat, this operation is also termed a panniculectomy. A pannus is the word used to describe the overhanging “apron” of fat and skin that folds over the pubic area toward the upper thighs. A saggy pubic area can be treated with a simultaneous “pubic lift” procedure. An “extended” abdominoplasty may be recommended to extend the scar lengths onto the hips and flanks to achieve skin tightening on the sides as well (flank plasty). But you have to stop the incision somewhere. Skin looseness affects the body all the way around to the back. A “lower body lift” is the term used to describe skin tightening all the way around the waistline; essentially an extended tummy tuck going all the way around to the back so the entire lower body skin is lifted. Some plastic surgeons do this procedure in one surgical setting, while others may prefer to stage the procedure for aesthetic reasons or patient safety. For example, I typically perform the abdominoplasty first, usually with breast contouring, followed by buttock lifting several months later.
Most patients do require multiple surgeries to tighten the skin on various parts of the body. Patients need to be realistic (with a large pocket book as insurance does not cover the cost), and know that their body will be a work-in-progress. There is no such thing as a “home run” in one surgical setting. Patient safety is paramount; these are big surgeries with long general anesthesia times (3-6 hours). Surgical plans are individualized per patient, taking into account the size of the patient, age, overall health, habits (smoking), motivation, and anticipated operating room time so that risks are minimized.
Scars from abdominoplasty are well worth the trade off. They are low, hip-to-hip or flank-to-flank, with an oval scar around the umbilicus. The internal abdominal muscles are tightened if they are bulging or separated. If you have a lap band port, typically the port is easily avoided and left undisturbed in left upper quadrant of your abdomen. Recovery is 2-3 weeks, followed by months of swelling and the need to wear a compression binder to keep swelling to a minimum. No core or aerobic exercise for 6 weeks after, so following a strict healthy diet is essential to optimize results. Weight gain will negatively influence the result. Weight stability for 1-2 years after your weight loss is mandatory before proceeding with body contouring surgery.
Massive weight loss also commonly affects the appearance of the breasts. Sagging is usually an issue, in addition to the loss of breast volume. Breast lift surgery is required to tighten up the skin envelope and raise and tighten the breast with the goals of an age-appropriate, natural and “perky” breast contour. The scars after breast lift are located around the areola, down the lower half of the breast, and under the breast fold (similar to an anchor pattern). In many cases, additional volume is required, and a saline or silicone breast implant is added simultaneously under the chest muscles (pectoralis major muscle). This is called “augmentation mastopexy” surgery. Keep in mind that there is no such thing as a permanent “superior pole fullness”. Implants are heavy and respond to gravity. If your tissues are loose and lax, which is common in massive weight loss patients, expect the possibility of reoperation for recurrent sagging over time, or for implant removal and replacement (as shell integrity is expected to last 10 years).
Patients are highly satisfied with the combination of breast and waistline contouring, and results are often life changing. It’s the best way to begin your body transformation. Second stage surgeries can involve various procedures, depending on patient priority, financial status, and desires. If the buttock and backside is loose and saggy, a buttock lift (think of an abdominoplasty in reverse) can be performed. A “Brazilian butt lift” refers to fat transfer to the buttocks to increase projection. In this case a donor site of fat needs to be available for liposuction to obtain the fat grafts. Upper back rolls can also be excised with resulting scars that can be oriented to lie hidden within bra straps in women.
Brachioplasty refers to arm skin tightening. The best candidates have loose skin and otherwise thin arms to obtain the most tightening of arm tissue without compressing underlying nerve and vascular structures. The main issue with arm lift surgery is the potential for a highly conspicuous scar running down the inner part of the upper arm. This scar can show in short sleeved clothing, tank tops, sleeveless dresses, and swimsuits. Therefore, not all patients opt for brachioplasty. Mini arm lifts with skin incisions placed in the armpit usually fall short of making any noticeable difference in the skin looseness affecting the upper arm.
Facelift and Necklift surgery works well to treat sagging skin of the lower face and neck, to create a youthful jaw line. Scars are well accepted, inconspicuous within the contours of the ear. Injectable fillers like Juvederm (www.juvederm.com) or Sculptra (https://www.sculptraaesthetic.com) can be added for facial wrinkles or areas of hollowing.
The lower extremities are more challenging to treat. The best candidates for a medial (inner) thigh lift have a very thin fatty layer. Suture material cannot lift and support heavy thighs. The scar is in an awkward and uncomfortable place within the groin. Because you need to walk after surgery, this area can experience high-tension forces; so permanent sutures need to be placed along firm tissues near the pelvic bone. The groin is sensitive and naturally difficult to keep clean and dry. Needless to stay, the procedure is uncomfortable with increased risks for delayed healing in the groin crease and small open areas that take longer to heal. There are additional risks of tissue stretch, scar widening, pulling sensations on the genital area, and poor results from the possibility of early recurrent skin sagging. With this surgery, expect a 50% improvement at best. Suture material cannot hold up the thigh as well as your hand does in the mirror. Do not expect any skin tightening effect below the mid-thigh, laterally, or near the knees with this procedure. With abdominoplasty and flank surgery, some mild degree of lateral thigh lifting is achieved.
Alternatively, thigh lifts can be performed using vertically oriented incisions running down the inner thigh from groin to knee. These are also complicated procedures with significant downtime, risks, and potential for conspicuous scarring. Extended thigh skin tightening surgery should be performed by board certified plastic surgeons with a high volume of experience in this anatomically challenging area.
For the knees and distal leg, there are not great procedures with reliably great results. There is also no treatment for diffuse cellulite affecting the lower extremity. The legs are technically the most challenging area to treat with the highest risks for complications and potential for unsatisfactory results, including early recurrent sagging and noticeable scars.
Body contouring after massive weight loss is an essential component of dealing with excess skin and allowing a patient who has lost significant weight to enjoy wearing clothes that fit properly and look attractive. Studies have shown that patients who undergo plastic surgery after massive weight loss are more likely to maintain their weight loss over time. Functional benefits include improved hygiene, less rashes and chafing, and increased ability to exercise, in addition to improvements in self-esteem and quality of life.
