Post Massive Weight Loss / Post Bariatric Surgery

The following information has been prepared to familiarize you with facts regarding a variety of surgical procedures that are utilized to tighten excessively loose skin, frequently after massive weight loss. A smaller group of patients, who are normal weight and have never been overweight, will present with loose enough skin to warrant surgical tightening in the inner arm, posterior trunk, buttocks or thigh regions. If you fall into the post massive weight loss category, you are first to be congratulated for loosing so much weight!

Study after study has demonstrated the benefits of weight loss in patients who are morbidly obese. Your heart and lungs will not have to work as hard. Your legs will have less weight to carry. If you had adult onset diabetes, it will surely have improved or even gone away after the weight loss. Unfortunately, as you have found, skin does not go back to its pre-stretched condition. Most patients who loose a large quantity of weight desire to have the excess remaining skin from their abdomens removed and their breasts uplifted, with or without an implant, or reduced. The tummy tuck and breast recontouring procedures are covered in separate sections entitled abdominoplasty and breast reduction/uplift. Post weight loss patients also frequently are left with loose neck skin or jowls, and these procedures are covered in the face lift section. This section will focus on procedures utilized to address skin laxity along the inner arms, upper and mid back regions, buttocks and thighs.

Twenty five years ago, it was rare to have a patient walk into a plastic surgeon’s office after substantial weight loss. But these days, we routinely see patients who have lost in excess of one hundred pounds. About three quarters of the massive weight loss patients we see did so with the assistance of bariatric surgery – such procedures have been designed to either decrease the size of the stomach pouch or some variety of “bypass” which shunts food down the intestines quicker without absorbing as many calories. With the advent of laproscopic surgery and the more sophisticated bypass and stapling techniques, the efficacy, safety and popularity of such “bariatric” surgery has sky rocketed. This year over 140,000 bariatric procedures will be performed in the United States, and the numbers keep climbing higher each year as more centers with expertise in such procedures open up. But a good quarter of the weight loss patients we see achieved their results the good old fashioned way, by altering their diets and by exercising regularly!

The areas which we can address with plastic surgery are the neck and face, breasts, inner arms, abdomen and back of trunk, hips, thighs and buttocks. As mentioned above, facial skin tightening, breast surgery and a straight forward abdominoplasty are covered elsewhere. Here, we will focus on procedures designed to improve the inner arms, posterior trunk, hips, thighs and buttocks.

In all of these areas, the problem is an excessive amount of skin. It must be stressed that some skin laxity in these areas is absolutely normal. Every patient over the age of 20 will have some skin laxity in these areas, and the only time they should be addressed surgically is if the amount of skin laxity is much more than average, and if the degree of correction to be achieved can be justified by the resultant scarring. Procedures such as liposuction, rhinoplasty, breast augmentation, eyelid surgery and a face lift most frequently do not leave any visible scars. Body contouring procedures, on the other hand, ALWAYS leave a long and wide scar – each patient will have to decide for themselves if the improvement in the skin laxity will be justified by the resultant scars, cost and risks of surgery.

An inner arm brachioplasty is an operation in which excess skin and fat from the inner arm, between the axilla (arm pit) and elbow, is removed and the remaining skin tightened. This is accomplished by excising a large ellipse of this excess skin. The resultant scar will run along the inner arm, hidden with your arm down along your side but definitely visible if a patient is wearing a short sleeve shirt and has their hands up in the air!

The posterior trunk can contain excess rolls of skin either continuing around the back at the level of the breast or lower down as a continuation of the abdominal skin rolls. The upper back excess can be excised by removing wedges and leaving the final scar at the level of a brassiere in a female. The lower trunk is usually addressed in conjunction with an abdominoplasty and is called a “belt lipectomy”. Such belt lipectomies result in a tightening of the abdominal wall and the lower posterior trunk, including the hip/thigh area and upper buttocks. The incision follows the fold along the lower abdomen, above the pubis, and continues on the backside just above the buttocks. Such scars, while noticeable when unclothed, are usually easily hidden within standard shorts. It is important to understand that during such procedures, a transverse wedge of tissue will be removed and the patient will experience a vertical tightening of the skin – if you pinch your abdomen or lower back vertically, a very significant tightening will be appreciated, but if one pinched horizontally, no appreciable tightening will be noted.

The lower buttocks and thighs can be tightened in a similar fashion, with the resultant scar location to be determined by the areas of your most significant skin excess. As with the belt lipectomy or abdominoplasty, the skin tightening will usually occur in one plane, usually vertically, and not result in significant horizontal tightening. If massive skin laxity is present, both a horizontal and a vertical tightening might be desirable. In such situations, a “T” shaped scar may be designed with a transverse incision along the upper inner thigh, perhaps extending obliquely onto the buttocks, as well as a vertical scar down the inner thighs towards or to the inner knees.

Most patients who have lost a lot of weight have multiple areas to address. These body contouring procedures can be combined to address multiple areas, with certain limitations and exceptions. It is not safe to address the inner thighs and abdomen at the same sitting because of blood flow interruption to the pubis and strip of skin between the inner thighplasty scars and abdominoplasty or belt lipectomy scars. But with either procedure, it would be safe to address, for example, the inner arms or breasts. Such procedures may also be combined with non-skin tightening operations such as liposuction, eyelid surgery or other procedures. Your overall health and age will also help determine how much surgery you can tolerate in one day. But even if you are in perfect health, it is unwise to electively schedule procedures that are designed to be longer than six hours in length because after that time, your chance of developing a blood clot in your calved or other complications will become more likely.

The operation is directed toward an improvement and will not in any way give you complete obliteration of all folds, laxity and stretch marks. You must accept the judgment of your plastic surgeon and realize that he will remove as much as is safe and suitable. Particularly in patients with thicker fatty layers or marked skin excess, it may be desirable to return for additional skin excisions to obtain an optimal result. Should this prove desirable, the patient will be responsible for all costs associated with all secondary surgical procedures.

The type of skin, degree of elasticity and age of the patient all influence the overall result that is obtained. The operation should not be undertaken if the patient’s weight is not stable or if a patient has not made a commitment to themselves to keep the weight off in the foreseeable future. While it is not necessary for the patient to reach a certain weight before surgery may be performed, it is desirable that the patient's weight be stable for at least six months prior to surgery and that the patient be at a weight he/she feels can be maintained after the procedure.

A common question is, "How long will the results of this procedure last?" This is impossible to state. Factors affecting the length of the result include age at the time of operation, physical conditioning afterwards, type of skin, and alterations in weight. In general, it is not necessary to repeat these procedures after an optimal result has been achieved. Should the patient wish to repeat the operation, regardless of the length of time since the initial operation, the degree of laxity or fatty excess remaining, each patient will be responsible for the cost of a subsequent procedure.

You are requested to read this information thoroughly and to discuss any questions which might arise with your surgeon before you give your consent to proceed with this procedure. You are also requested to keep this form as a reference in the postoperative period.