Plastic Surgery Forum

by Joseph F. Capella, MD

Patients considering weight loss surgery and those who have already undergone a bariatric procedure should be aware of the changes that occur in the body following massive weight loss. With few exceptions, individuals following significant weight loss develop generalized or focal areas of excess skin.

The primary cause of excess skin following weight loss is relatively simple. Similar to pregnancy where the muscles, skin and other tissues of the abdominal wall expand to accommodate the fetus, a similar process occurs with the accumulation of fat in the body. There are important differences however. The process of fat accumulation in morbidly obese individuals often begins during childhood or adolescence, prolonging the period of tension on the skin. In addition, the area of tissue expansion in obesity is generalized rather than limited for the most part to the abdomen.

With weight loss and following the delivery of a baby, the affected tissues tend to retract. When the tissues do not return to their previous state it is because they have been permanently damaged. In the case of skin, the elastic fibers have been broken. This can give the appearance of striae, a condition often seen on the breasts and abdomen following pregnancy. How closely the skin and other tissues of the body resemble their appearance prior to pregnancy or obesity depends on similar factors.

Probably the most important determinant of how much loose skin an individual will have following weight loss is age. Younger patients tend to have less loose skin. The next most important factor is the amount of weight loss. An individual who loses 250 lbs. is likely to have more excess skin than somebody losing 80 lbs. Other less important variables include complexion, amount of sun exposure received over a lifetime, heredity and whether somebody is a smoker. Fair skinned people in general tend to develop more loose skin than darker individuals. Sun worshippers tend to sustain more tissue damage over the years and consequently more loose skin following weight loss. Some people tend to have ?better? skin than others of similar complexion and lifestyle. This may be the result of hereditary factors that are not readily apparent. Finally, smoking breaks down collagen, a major component of skin and other structural components of the body. Smokers develop more loose skin than their non-smoking counterparts.

Treatment Options
The development of excess skin following weight loss can be a disturbing side effect for some individuals. Fortunately there are effective means of treating this problem.

Exercise
Exercise that includes increasing muscle tone can tighten connective tissue between muscles and overlying skin. A regular exercise regimen is helpful to maintain ones weight following bariatric procedures and can serve to tighten loose skin to some degree.

Body Contouring Procedures
For those losing over 80 to 100 lbs., surgical procedures to tighten skin may be needed to achieve an aesthetically satisfactory outcome. Plastic surgery to improve body contour has advanced greatly over the last two decades. Below is a review of the latest techniques in body contouring relating to the areas of most concern following weight loss.

Abdomen, Thighs and Buttocks
The abdomen is usually of greatest concern to individuals following massive weight loss. In both men and woman, excess fat is stored both in the abdomen and beneath the skin of the abdominal wall. Consequently, following weight loss, there tends to be both excess abdominal wall skin and loose muscles. In addition to the aesthetic concerns, the abdomen often presents as a functional problem following weight loss. Large amounts of hanging skin along the lower abdomen can lead to the collection of moisture between the skin folds resulting in a condition called intertriginous dermatitis. The skin is often irritated, red and painful. On occasion the skin may breakdown and bleed or even become infected. Non-surgical means of treating this problem include maintaining the skin folds dry. This can be frustrating and is only a temporary solution to the problem. Fortunately with proper documentation insurance companies may recognize this problem and provide coverage for the surgical removal of the excess skin, a procedure called panniculectomy. Panniculectomy in the region of the abdomen is also referred to as an abdominoplasty or tummy tuck. The technique usually involves tightening the muscles of the abdomen and removing excess skin as well.

Addressing the excess skin of the abdomen is often very satisfactory following pregnancy but is usually inadequate following massive weight loss. As mentioned earlier, weight loss following bariatric procedures is generalized; consequently, excess skin is not just confined to the abdomen but involves the thighs and buttocks as well. For these reasons, some surgeons almost exclusively perform a procedure called a body lift on their weight loss patients. The operation involves an abdominoplasty, thigh and buttock lift all at one time. The operation very effectively addresses loose skin and cellulite along the thighs and buttocks as well as the abdomen. Patients are often exhilarated just to learn that that such an operation exists. While the scar is lengthy, it is confined to the waistline and is hidden by conventional underwear, panties or a bikini. Both men and women find the operation very rewarding.

Breasts
Breast size and shape often change significantly in both men and women following weight loss. The effects of aging and gravity cause the breasts to sag with time. Massive weight loss greatly accelerates this process. As women advance from their teens to twenties and into later years, the glandular portion of breast is replaced with fat. Glandular tissue is more firm than fat. Consequently, even without weight loss, women's breasts become less firm and consequently change shape over time. Women who sustain significant weight loss in the fourth and fifth decades of life can have a marked change in breast size and shape. By this age, a significant portion of the breast glandular tissue has been replaced with fat and therefore marked weight loss will lead to a rapid decrease in the amount of breast tissue. The skin unable to retract completely produces severely ptotic (sagging) breasts. This condition is called breast involution.

The treatment options for women's breasts following weight loss are several. If a woman desires larger, fuller breasts but has little sag, an implant alone may be satisfactory. This scenario is not the norm, however. More often women have concerns about sagging and want to be larger. In this case a breast lift or mastopexy is needed, in addition to placement of an implant. The options for breast lift are several. For small amounts of sag, a cirumareolar technique can be used which only involves an incision around the areola. For moderate amounts of sag, a vertical mastopexy can be used. With this technique, there is an incision around the areola as well as extending from the areola to the base of the breast. For severe sagging or ptosis, an anchor type incision may be necessary. The above-mentioned incisions are utilized in addition to one at the base of the breast. For patients not desiring to be larger and who have an adequate amount of breast tissue, a lift without an implant may produce an aesthetically satisfactory outcome.

The problems in men are similar; however the terminology and treatment is slightly different. In the obese state, men tend to have large breasts. With weight loss, some fat and glandular tissue remains. Depending on a man's age, degree of weight loss and other factors mentioned above, he might end up with large breasts relative to his torso, large and/or sagging breasts or satisfactory appearing breasts. Large and/or sagging breasts in men is called gynecomastia. For men with large breasts following weight loss, liposuction alone may provide adequate treatment. This is not typical however. Most men who present for treatment have concerns about both size and sag. Some surgeons' preference for this scenario is to do a two-staged procedure. In the first stage liposuction is performed to remove excess fat and some glandular tissue. Over the next several months, the breast skin will retract to some degree. Three to six months later, the patient is seen to evaluate the situation and determine whether a satisfactory outcome has been achieved. Delaying a second procedure allows for significant skin retraction to occur. If a skin tightening procedure is desired, it is likely to require shorter incisions. The incisions for a mastopexy in men are similar to women, however there is one additional option. For men with a relatively small amount of breast sag, a skin the tightening procedure can be performed from the axillary region or armpit, concealing any scars. Furthermore, because men often have hair on their chests, scars are well concealed and thus better tolerated.

Arms
Loose skin and excess fat at the arms can be a source of great consternation for both men and women following weight loss. For some patients it is of greater concern than any other area. A patient may feel forced to wear long sleeved shirts at all times.

There are three surgical options for the weight loss patient seeking improvement in the appearance their arms. For individuals with excess fat and relatively good skin tone at the arms, liposuction alone may provide a satisfactory outcome. Once again, this is not the norm. Patient seeking improvement usually have some degree of excess fat and loose skin. When the amount of excess skin is mild, a modified form of brachioplasty or arm lift can be performed. With this technique, the excess skin of the arm and armpit is tightened only from the armpit, leaving a well-concealed scar. This procedure is often combined with liposuction. This operation is effective only in individuals with a relatively small amount of excess skin. The classic procedure for arm lift involves a scar in the armpit as well as along the inside of the arm. It is often combined with liposuction. This operation is the most effective for individuals with large amounts of excess skin at the arms. The drawback of this procedure is of course the scar along the inner aspect of the arm. Most patients unhappy with large amounts of skin at the arms are willing to have this scar in exchange for markedly improved arm contour.

Face
Massive weight loss can accelerate the appearance of facial aging. With weight loss the fatty layer beneath the skin thins as occurs with normal aging but at a much faster rate. Part of what creates a youthful appearing face is a thicker layer of fat in certain parts of the face. With age and significant weight loss, the laugh lines and other wrinkles on the face become more prominent. One important difference between the effects of the normal aging process and rapid weight loss is the excess skin that develops along the neck. The neck serves as a repository for fat in most obese individuals. Weight loss consumes much but not all of this fat. Consequently, weight loss patients often complain of excess skin and fat at the neck.

The treatment options for weight loss patients are essentially the same as their non-weight loss counterparts. A facelift which almost always incorporates a neck lift treats very effectively the deep wrinkles of the face as well as the excess fat and skin of the neck. The technique of face lifting usually involves an incision beginning in the scalp above the ear, continuing immediately in front of the ear and extending around and behind the ear and just inside the hairline of the scalp below the ear. The skin of the face and neck is elevated and the excess removed. Other components of the operation usually include tightening the superficial muscle layer just deep to the skin and removing the excess fat of the neck. Face lifting can significantly refresh the appearance of weight loss patients.

Timing and Approach to Plastic Surgery
Body contouring procedures should be considered only after ones weight has stabilized after a bariatric procedure. This can range from 7 to 18 months, depending on an individual's preoperative weight. Performing a skin tightening procedure prior to weight stabilization may result in the need for further skin tightening in the future.

Patients often want all body contour concerns addressed as soon as possible. Unfortunately, providing the highest quality plastic surgery often means having one procedure performed at a time. Patients usually present for consultation knowing exactly which area of their body concerns them the most. While most surgeons will most often begin with their preference, it is preferred not begin with breast surgery if abdominal wall tightening is being contemplated. An abdominoplasty or body lift can affect the breasts to some degree.

At the initial consultation with weight loss patients, they should be cautioned that several operations might be needed to achieve a satisfactory overall body contour. It is preferred to wait to at least three months between operations.

Body contouring procedures following massive weight loss are usually extremely gratifying for both the patient and surgeon. The results are usually dramatic and provide a significant functional and aesthetic benefit to the patient.

Dr. Capella is a certified by both the American Board of Plastic Surgery and the American Board of Surgery. He is a member of the American Society of Plastic Surgeons and the American Society for Bariatric Surgery. Dr. Capella is a clinical assistant professor of surgery at the University Medical and Dental School of New Jersey. Click here to view Dr. Capella's web site