Dramatic weight loss, whether through bariatric surgery, diet, or exercise, is a significant achievement. However, a common side effect is excess, loose skin that can impact both physical health and emotional well-being. This article will explore the reasons behind excess skin after weight loss, the surgical options available to address it, and what to expect before, during, and after surgery.
Why Excess Skin Occurs After Weight Loss
Excess skin after significant weight loss typically occurs because the skin has been stretched beyond its elastic limit. When a person gains weight, the skin expands to accommodate the increased volume. This stretching can affect the skin's elasticity, making it difficult for it to retract fully after substantial weight loss. Several factors contribute to this phenomenon:
- Skin Stretching: The skin stretches to adapt to the extra volume from weight gain, affecting its elasticity.
- Loss of Elasticity: Over time, the skin loses its ability to return to its original shape. Aging and repeated stretching from weight gain exacerbate this loss.
- Rapid Weight Loss: When weight is lost quickly, the skin may not have enough time to adjust, leading to sagging and excess skin.
- Personal Factors: Age, genetics, and the amount of weight lost all play a role in the amount of excess skin that remains.
Common Areas Affected by Excess Skin
After massive weight loss, excess skin is commonly found in several areas of the body:
- Abdomen: Loose skin, especially in the lower stomach, is a frequent concern. Many weight loss patients are left with a significant "apron" of skin, called a pannus, hanging from below the belly button.
- Thighs: Extra skin can appear on the inner thighs, causing irritation while walking.
- Arms: Sagging skin on the upper arms is a common issue.
- Breasts: Sagging or "deflated" breasts may occur, particularly in women.
- Face and Neck: Less commonly, sagging jowls, a double chin, or a less-defined jawline can result from facial fat loss and decreased skin elasticity.
Physical and Emotional Impact of Excess Skin
Excess skin can have both physical and emotional consequences. Physically, it can limit mobility, restrict clothing options, and cause medical issues such as painful rashes, sores, and infections. The additional loose skin on the body could make it harder to bathe and get around day to day. It might even keep people from doing their favorite activities or hobbies. Specific effects include:
- Chafing, rashes, and pain near skin folds.
- Increased moisture in skin folds, leading to potential infections.
- Difficulty exercising.
Emotionally, excess skin can be a constant reminder of past weight or lead to feelings of self-consciousness and low self-esteem. Many people see their extra skin as a constant reminder of their past weight or feel less confident in their appearance overall.
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Types of Excess Skin Removal Procedures
Several surgical procedures can remove excess skin and improve body contours. Most people need a combination of surgeries to achieve their desired look. A doctor can help determine which procedures are most beneficial. Post weight loss skin removal is personalized to a patient’s individual needs and goals; no two procedures are exactly alike. Typically, surgery involves a combination of body lifting procedures and is tailored to address a patient’s areas of greatest concern.
Common excess skin removal procedures include:
- Arm Lift (Brachioplasty): Removes excess skin that hangs from the upper arm, providing a sleeker appearance. Excess skin and fat are removed through an incision on the inside or back of your arm. This procedure may include liposuction to improve contours.
- Back Lift/Bra Line Lift: This procedure often combines liposuction and skin removal to reduce “bra rolls” and restore a smoother, firmer upper back contour.
- Breast Lift (Mastopexy): Firms up breasts by tightening tissue and removing excess skin. Many female patients are bothered by sagging or “deflated” breasts following weight loss. A breast lift removes excess skin and reshapes the breast to achieve a firmer, lifted contour and improve symmetry. Breast implants can be placed during a breast lift to restore lost volume or increase size.
- Facelift (Rhytidectomy): Gives the face a smoother, younger appearance and gets rid of excess skin around the neck.
- Lower Body Lift: Removes excess skin and fat from the stomach, buttocks, and outer thighs. A lower body lift tightens tissues on the abdomen, buttocks, and thighs. It is one of the most common post weight loss procedures, and also one of the most extensive. Surgery involves a long incision, placed just above the hip bone, which runs around the circumference of the body.
- Panniculectomy: Removes the apron of excess skin (pannus) that hangs below the belly button. Many weight loss patients are left with a significant “apron” of skin, called a pannus, hanging from below the belly button. A panniculectomy removes this apron of skin to restore a smoother, firmer torso. The incision is similar to that for a tummy tuck, located just above the pubic bone. This procedure removes the excess skin and tissue of the lower belly that can hang over the genitals and onto the thighs. The length of your incision is determined by how much skin must be removed. This procedure may be covered by insurance if the excess skin is causing a medical concern, including skin rashes.
- Thigh Lift: Gives the inner or outer thighs a sleeker appearance. Dramatic weight loss often results in an excess of skin gathered around the buttocks and thighs. A thigh and buttock lift removes excess skin and fat and restores a firmer, smoother, and more slender appearance to the legs and buttocks. Incisions for thigh and buttock lift surgery vary depending on the location and amount of skin to be removed. A crescentic thigh lift removes skin from the upper inner thigh. A vertical medial thigh lift removes excess skin down the entire inner thigh.
- Tummy Tuck (Abdominoplasty): Removes excess skin and tightens weak or separated abdominal muscles, creating a smoother, firmer abdomen. Removes excess fatty tissue and skin, and tightens abdominal muscles to create a smoother, firmer abdomen. The incision is made across the lower abdomen, just above the pubic area. A complete abdominoplasty requires repositioning your belly button.
Liposuction and Fat Grafting
Liposuction can help remove stubborn fat deposits, but it isn’t a weight loss surgery. Liposuction is a procedure to remove excess fat deposits from the chin, neck, cheeks, upper arms, breasts, abdomen, buttocks, hips, thighs, knees, calves, and around the ankles. Fat grafting may be combined with another procedure to enhance the cosmetic effect when too much fat is lost in certain areas. Liposuction is performed to remove fat from one part of the body -- usually your thighs, belly, or buttocks.
Fat grafting may be combined with another procedure to enhance the cosmetic effect when too much fat is lost in certain areas. Volume can be restored using your own body tissue with fat grafting.
Preparing for Excess Skin Removal Surgery
Before undergoing excess skin removal surgery, it's essential to follow your doctor’s recommendations. Preparation may include:
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- Getting blood work (lab tests).
- Stopping certain medications that increase bleeding risk, such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
- Avoiding vitamins and herbal supplements.
- Quitting smoking or using tobacco products.
What to Expect During Surgery
Excess skin removal often takes place in stages, requiring multiple surgeries. Depending on the procedures, surgery may occur in a hospital with an overnight stay or at a surgical facility as an outpatient procedure. Certain procedures, such as a lower body lift or a panniculectomy combined with a tummy tuck, can occur during the same surgical appointment.
Important Considerations
- Timing: Excess skin removal surgeries can only take place after bariatric (weight loss) surgery. A plastic surgeon can’t remove the excess skin until you lose the extra weight. It may take one to two years to achieve your goal weight after bariatric surgery. You also need to maintain that weight loss for at least six months before getting body contouring procedures. You have reached your goal weight and your weight has remained stable for at least 6 months. You are in good general health.
- Surgeons: Bariatric surgeons perform weight loss procedures like gastric bypass and gastric sleeve. Plastic (cosmetic) surgeons perform body contour procedures. Skin removal surgery is a specialized subset of cosmetic surgery and should only be performed by a highly experienced, qualified cosmetic surgeon with specific training in body contouring procedures. Always confirm a cosmetic surgeon’s training and experience. Choosing a cosmetic surgeon who is certified by the American Board of Cosmetic Surgery is a good first step. ABCS diplomates have undergone formal training in body contouring surgery and exclusively operate in fully accredited surgical facilities.
- Personalized Approach: Post weight loss skin removal is personalized to a patient’s individual needs and goals; no two procedures are exactly alike. Typically, surgery involves a combination of body lifting procedures and is tailored to address a patient’s areas of greatest concern.
Recovery After Excess Skin Removal Surgery
Recovery depends on the procedures performed and the extent of skin removal. More extensive procedures, such as a lower body lift, will require a longer recovery and may necessitate a short inpatient stay. Temporary drains may be placed for the first 1 to 2 weeks to ease swelling, and discomfort can be significant for the first few days.
Potential Risks and Complications
Excess skin removal surgery, like any surgical procedure, carries potential risks, including:
- Bleeding
- Infection
- Wound healing concerns
- Scarring
- Unsatisfactory results
- Reactions to medicines
- Breathing problems
- Blood clots
- Nerve damage
- Skin loss
- Poor wound healing
- Fluid buildup under the skin
- Tissue death
Preventing Excess Skin After Weight Loss Surgery
While loose skin often cannot be completely avoided after weight loss surgery, certain steps can minimize and manage it:
- Gradual weight loss: Allows the skin more time to retract and adjust to the changing body shape.
- Staying hydrated: Keeps the skin supple and resilient.
- Strength exercises: Help build muscle to fill the space left from fat loss, reducing the appearance of sagging skin.
When to Consider Skin Removal Surgery
It is generally recommended to wait until weight has been stable for at least a year before considering skin removal surgery. This ensures the skin has reached its "new normal," making the final amount of excess skin clear. Undergoing surgery before weight stabilizes can affect the end results if further weight loss or gain occurs.
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Benefits of Excess Skin Removal Surgery
The benefits of excess skin removal surgeries can include:
- Improved mobility and hygiene.
- Increased comfort and confidence.
- Enhanced body image.
Panniculectomy in Detail
Panniculectomy is a specific surgery to remove stretched-out, excess fat and overhanging skin from the abdomen, often necessary after massive weight loss. The skin may hang down and cover the thighs and genitals. This procedure differs from abdominoplasty, which also tightens abdominal muscles. Sometimes, both surgeries are performed together.
Surgical Procedure for Panniculectomy
- Anesthesia: General anesthesia is administered to keep the patient asleep and pain-free.
- Incision: The surgeon may make a cut from under the breastbone to just above the pelvic bone, along with a horizontal cut in the lower belly, just above the pubic area.
- Removal of Excess Tissue: The overhanging extra skin and fat, called an apron or pannus, is removed.
- Closure: The cut is closed with sutures (stitches).
- Drainage: Small tubes, called drains, may be inserted to allow fluid to drain out of the wound as the area heals. These will be removed later.
- Dressing: A dressing is placed over the abdomen, and a binder may be required.
Why Panniculectomy Is Performed
After significant weight loss (100 pounds or more), the skin may lack the elasticity to shrink back to its natural shape, causing it to sag and hang. This extra skin can make it hard to keep clean, walk, and perform daily activities. It can also cause rashes or sores. Clothing may not fit properly. Panniculectomy removes this extra skin, helping patients feel better about themselves and more confident in their appearance. Removing extra skin may also reduce the risk of rashes and infection.
Risks of Panniculectomy
Besides general anesthesia and surgery risks, specific risks of panniculectomy include:
- Scarring
- Infection
- Nerve damage
- Loose skin
- Skin loss
- Poor wound healing
- Fluid buildup under the skin
- Tissue death
Before Panniculectomy
The surgeon will ask about your detailed medical history and examine the excess skin and old scars, if any. Patients should inform their surgeon if they are pregnant or taking any medications, supplements, or herbs.
During the week before surgery, patients may be asked to temporarily stop taking medicines that keep their blood from clotting, including over-the-counter medicines and supplements such as aspirin, ibuprofen, naproxen, and vitamin E.
After Panniculectomy
Patients typically stay in the hospital for about two days after surgery, possibly longer for more complex cases. Walking a few steps is encouraged soon after recovery from anesthesia. Pain and swelling are expected for days after surgery, and pain killers will be prescribed. An elastic support may be recommended to provide extra support while healing. Strenuous activity and straining should be avoided for 4 to 6 weeks. Most people can return to work in about 4 weeks. It takes about 3 months for swelling to subside and wounds to heal, but final results and scar fading can take up to 2 years.
Insurance Coverage
Panniculectomy is not always covered by health insurance, as it is often considered a cosmetic procedure. However, if it is done for a medical reason, such as hernia, insurance may cover the costs. It is crucial to check with the insurance company before surgery to understand the benefits.