Excess Skin Removal After Extreme Weight Loss

Excess skin removal for extreme weight loss

• Obesity is a growing epidemic in developed countries throughout the world. Obesity causes significant public health problems, including an increase in type 2 diabetes, cardiac disease, and degenerative joint disease. A simple indicator of obesity is the body mass index (BMI), which is the weight of an individual in kilograms divided by height in meters squared.
• Over the short term, diets can be effective for losing weight; however, only about 5% of people maintain long-term weight loss from dieting. Because of this, many people who are severely obese have turned to bariatric surgery as a more definitive treatment.
• Bariatric surgery for weight loss in individuals who are obese is becoming a safer and more commonly performed surgery. During weight gain, the skin expands to contain the underlying fat and can often lose elasticity. If older individuals or people whose weight was excessive for many years lose weight, the skin and underlying tissue do not naturally return to their original size. A number of surgical procedures for removing excess skin and fat are available.
• Surgical techniques for excess skin removal began in Brazil and France more than 40 years ago but were fraught with complications, poor scarring, unnatural contours, long recovery time, and inconsistent results. Over the past 15 years, with the large increases in the number of people with excess skin, skin removal surgery has undergone several improvements. One innovation, the body lift, which was developed by Dr. Ted Lockwood in Overland Park, Kansas, has produced aesthetically pleasing results in selected patients.
• The treatments of excess tissue can involve extensive surgical procedures. The procedures vary from commonly performed procedures such as abdominoplasty (tummy tuck), mastopexy (breast lift), inner thigh lifts, and brachioplasty (arm lift) to the more complicated procedures such as high lateral tension abdominoplasties and lower body lifts.
• Advantages of body lifts include improved skin quality, long-lasting results, smoother natural contours, and better control of results. Disadvantages of body lifts include more complex surgery (requiring more expertise), longer operating time, long scars, longer recovery after surgery, and increased cost.

Preparation for the procedure involves losing weight and reaching a stable body weight prior to the procedure. This is unlike the preparation involved for liposuction. If problem areas persist, liposuction may be performed prior to the excess skin removal procedures or, if only small areas are involved, at the same time as the surgery for excess skin removal. There are inherent significant risks when liposuction is performed in areas adjacent to flap excisions required for body lifts due to the altered blood flow to the tissue, which is already compromised due to the tissue excess.

Many options are available with excess skin removal surgery. Thus, many people choose to meet with a surgeon at least twice or to seek a second opinion before embarking on such procedures. When choosing the timing of these procedures, considering the fact that people are at risk for nutritional depletion after massive weight loss is important. Discussing this issue with a primary-care doctor or bariatric surgeon may be useful. The usual preoperative health check, blood work, possible banking of one's own blood (if needed) and avoidance of any blood thinners (for example, aspirin, and ibuprofen) are all necessary and desirable for safety and a favorable outcome. Many of the procedures are performed in stages, with several months of recuperation between each stage. Additionally, many procedures are being performed by teams of plastic surgeons with at least two surgeons plus assistants in order to minimize the operative time and reduce risks to the patient.

Additional concerns of nutritional deficiency must be addressed in people who have undergone bariatric surgery. Folate, vitamin B-12, and iron deficiencies must all be corrected prior to major surgery. 

About 2-4% of patients in the population also have an antiphospholipid antibody syndrome, which is a condition of the immune system that creates an abnormal tendency toward blood clots. This should be investigated prior to surgery in those patients deemed clinically to be at risk.

The planning of multiple procedures is also important. Individuals need to decide which areas of the body bother them the most and work with the surgeon to come up with an individual surgical plan that best meets their needs. People commonly elect between one and six procedures, depending on their wishes. Excess abdominal skin is often the most bothersome and can be addressed by abdominoplasty, panniculectomy (the removal of superficial abdominal fat), or body lift. An example of a three-stage procedure is as follows:

• First stage: body lift and, occasionally, breast lift
• Second stage: involves the extremities and breast surgery or breast revision
• Third stage: the face and neck areas

With potential revision surgeries, as many as six stages are possible.

For major lifts, the body is often marked for surgery the day before the surgery.

The procedures are performed with the patient under general anesthesia. The more extensive or involved procedures are often performed in a hospital. Tummy tucks, arm lifts, liposuction, and inner thigh lifts may be performed in a day surgical setting on an outpatient basis, depending upon the extent of the procedure.

Hypothermia (the body becoming too cold) is a concern for major procedures. Hypothermia must be prevented because it increases the risk of lung problems, infection, and bleeding, and hypothermia also slows wound healing. The patient's temperature must be kept above 35 ºC (95 ºF).

Deep vein thrombosis (DVT) must also be prevented with compression stockings, a medication called low molecular weight heparin, or both. Because birth control pills increase the risk of DVT, the patient may be advised to stop taking them prior to surgery.

Recuperating from extensive surgical procedures can take time. Most people remain in the hospital for 24-48 hours after the surgery. Walking is important on the day of surgery. Sutures generally dissolve or are removed after a few days, and drains (if used) are usually removed after one to three weeks. Many surgeons advise using compression garments to improve long-term contour. Physical therapy may be necessary for help with return to full activities in this patient population after extensive procedures, especially those involving the arms.

After a high lateral tension abdominoplasty or inner thigh lift, it's usually a few days until the person can walk normally, a few weeks until the person is able to carry 10-15 pounds, and a few months before the full or vigorous activity is possible. This is in contrast to liposuction, for which return to full activity is often measured in days.

Subsequent procedures are performed based on the original plan, but can be modified depending on the response to the first stage of the procedure. Asymmetries are common, and healing problems are more significant with greater weight loss. Revisions are often necessary.

Complications are common in patients after major weight loss but can also occur in patients with less severe changes in body weight. The most common complication is a fluid collection under the skin (seroma). Drains are frequently used to minimize this complication and are usually removed after one to three weeks. Infections, wound breakdown, reaction to sutures, and hypertrophic scarring can also occur.

The risks of a given procedure are best discussed with the surgeon. In general, more extensive operations have higher complication rates. The usual risks such as possible blood loss, hematoma (mass caused by accumulation of blood) or seroma formation, and infection vary depending on the procedure, site of surgery, and facility.

People who are slightly overweight or mildly obese often obtain excellent results from excess skin removal. From an aesthetic standpoint, people with massive weight loss have results that are less pleasing, but they often have dramatic functional improvements such as an increase in the ability to exercise and a decrease in rashes because of the reduction of skin folding. Although long incisions are often necessary for maximal skin removal, the use of the superficial fascia (body layer) to reduce the tension on the surgical closure has resulted in scars that most people find acceptable. Improvements in excess skin removal surgery allow for safer and more effective results.

Excess skin removal surgeries are usually cosmetic in nature and should be considered when an individual desires to correct problems with skin excess. In limited cases, these procedures can be considered medically necessary when the excess skin impairs movement or when a rash occurs that is not effectively treated with medication.