Excess Skin and Body Contouring Post-Bariatric Surgery

The goal of bariatric surgery is weight loss – substantial weight loss – and a reduction of medical problems caused by being severely overweight. It may take some time, weight loss following bariatric surgery may take up to 18 months of hard work to reach a steady goal weight, but when the surgery is successful and you follow good eating and exercise habits, the weight comes off.

Excess Skin and Weight-Loss

It’s good to keep in mind that you’re on the final stage of returning your body to a healthier, better-looking condition. To help you through this stage you can consider body contouring and excess skin removal to improve the shape and tone of your underlying tissue. Although the skin incisions are significant, the result is a more normal appearance to the body, with smoother contours.

When the effects of weight loss are too visible

The loss of a substantial amount of weight has many positive effects – for example, reduction of blood pressure, decrease of diabetic symptoms, and a general improvement in health and outlook. However, major weight loss can result in folds of excess skin and body tissue. In some cases, this can hinder some normal activity such as bending or arm movement.

The most common physical result of substantial weight loss is the “apron” effect (circumferential excess), where loose skin and tissue hangs over the lower abdomen, hips and sometimes the buttocks. Occasionally, the area between the apron and body skin retains moisture, supporting bacteria that may cause inflammation and sometimes infection.

It’s in the nature of most people’s skin that such dramatic remainders of the previous stretching don’t disappear, even with targeted physical exercise. Much like the effects of a pregnancy, this makes large folds a permanent feature of the body, which may be a psychological and sometimes physical problem. It also makes them candidates for surgical removal through skin tightening and body contouring.

To be a candidate for this kind of reconstructive surgery the patient should meet some health criteria:

• Your weight trend should be stable for at least a year with no further weight loss expected.
• It may take one or two years for your skin to shrink as much as possible and for your diet to normalize.
• Your diet and nutrition level should be well balanced and steady. Certain deficiencies, such as lack of protein, can slow down the healing process after surgery. In a similar way, if you have started smoking after your bariatric surgery then you must quit at least 6 weeks before surgery to minimize the risk of serious complications and not have smoking slow down the recovery.
• General good health is important for smooth recovery from contour surgery. If you have heart conditions, diabetes or other chronic illness, your primary care physician may advise you against contour surgery.
• Mental stamina is important. You should be prepared and mentally stable to handle the rigors of surgery and recovery. Realistic expectations are also important. The surgery will make a big difference in the shape of your body, but it won’t make it like a teenager, nor will it stop the aging process.

When is body contouring surgery after bariatric surgery the right choice?

As might be expected, the advent of less or non-invasive techniques for tightening skin or removing body fat draw attention. Of course, diet and exercise are the oldest and still probably the best methods, but they are now joined by various commercial approaches such as mesotherapy (lipodissolve), thermage (heat dissolution of fat) and ultrasound. For the most part, however, these approaches don’t apply to the situation where weight-loss has already occurred and the problem is remaining loose skin and tissue (mostly not fat).

For most people under most circumstances, removal of post-bariatric excess skin and body contouring involves significant surgery – it requires an O.R. with skilled surgeon(s) and support staff and the procedure may require up to several hours. As with any extensive surgical trauma, there are risks of complications from anesthetics, shock to the body, bleeding and infection. Consequently, while the reasons for body contouring may be cosmetic, the approach to the surgery should be considered seriously as would any major medical procedure.

It’s also important to understand that most insurance companies and government medical programs do not typically cover body-contouring surgery, as they consider the procedure cosmetic. In some cases, they may not cover the cost of any complications that arise from the surgery.

Acquiring the right shape

As mentioned, muscle tone has little or nothing to do with loose skin. In most cases, physical exercise that builds muscles and body strength will not tighten folds of loose skin. This is an issue of tissue resilience, which varies between individuals. For most people, Body contouring may have three major elements:

• Tightening the skin, which usually involves an incision, removal of a portion (strip) of skin and then suturing the skin back together.
• Removal of underlying epidermal tissue, which sometimes includes fatty tissue, although with weight loss conditions this may be less common.
• Restructuring of underlying musculature, especially in the abdomen.

Abdominoplasty (tummy tuck)

Some people have only the skin and fatty tissue removed from the area of the abdomen, however, in some cases it is advisable or necessary to also reconstruct or reshape the abdominal muscles. This is usually performed through a full abdominoplasty.

Brachioplasty (arm lift)

Massive weight loss may leave some people with loose and droopy skin from the underside of their arms, through the armpit area and onto the chest. To tighten this loose skin, the brachioplasty procedure uses a horizontal incision, usually from elbow to arm pit or chest, removes the excess skin and underlying tissue and then sutures the tightened skin together. This reshapes and smoothes the skin of the arm. There is usually a residual scar from the line of the incision, which is not generally visible on the underside of the arm.

Face and neck lift (lifting facial droop)

Dramatic weight loss can leave the skin of the face and neck sagging, creating eye bags, cheek pouches and chin jowls. Surgically removing the excess skin restores the normal contours and smoothness of the face and neck.

Breast lift

As with other parts of the body, the skin and tissue of the breasts (for women and sometimes men) can become flaccid. Surgical lifting through removal of skin and underlying tissue can restore a normal breast profile. Breast implants are technically more challenging as sometimes not possible becuase of poor skin condition after massive weight loss.

Belt Lipectomy (lower body lift)

This a generic term for a number of procedures to remove excess skin and fatty tissue from the below the level of the chest. This can include the abdominal area from front to back, buttocks, groin and inner thigh, and around the upper and lower thigh. In the case where this is a weight loss related operation, it does not usually involve liposuction.

Very often, the belt lipectomy involves what surgeons call circumferential incision, a single continuous incision from the belly, over the hips, and around the back. This particular approach is often appropriate where the elimination of the hanging “apron” of skin is the foremost goal. The same incision, with possible ‘bikini cuts’ (side cuts) can be used to perform abdominoplasty, pulling up a droopy pubic region, creating a waist, lifting the thighs, and lifting and defining the buttocks.

Total body lift

You can see from the list of sectional contour surgery above that restoring the body to a normal profile after massive weight loss can potentially involve almost the entire body. This “total body lift” is an individual matter that you should carefully consider with the help of your primary physician and the plastic surgeon. Such systematic re-contouring of the body is a major undertaking with multiple surgeries and lengthy recovery periods.

Post-operative recovery after body contouring surgery

Most patients readily understand that with the large incisions and tissue removal of body contouring there is likely to be a substantial recovery period and some pain. Body contouring surgery is likely more painful than your original bariatric surgery. How much pain depends on the sensitivity of the individual. Most patients can expect periodic pain during the first few days and will require pain medication. Most of the acute postoperative pain will dissipate in 7 to 10 days, although additional pain medication may be required.

A  usual hospital stay following major contouring surgery typically varies between 0 to 3 days. Additional days provide time for physicians to observe your recovery and watch for conditions such as hematoma (blood pooling) or seroma (inflammatory fluid) in the areas of the surgery that might require drainage.

As the body adapts

Not to put too fine a point on it, full recovery from body contouring can be lengthy and uncomfortable – which is another way of saying that some pain is part of the process. The recovery period for extensive body contouring is usually several months, although much depends on general health and other individual characteristics.

Because the lengthy incisions for body contouring are located where movement can stress them, caution with physical activity is important. The simplest instruction during the adaptation period when your body is adjusting to the new contour is – be careful. Especially in the first weeks or months, sports and activities with sudden violent movement are risky; this includes tennis, golf and most team sports. If you want to get back into shape for that kind of activity – work up to it and get clearance from your doctor and related specialists.

As with any kind of surgery, if you find yourself short of breath, having chest pains or other feelings of uneven heart activity – seek medical attention immediately. These could be signs of a cardiovascular reaction.

At the end of the recovery process, the combination of weight loss through bariatric surgery – and the adoption of healthy diet and exercise habits – may improve your health and well-being. The addition of contour surgery and skin removal will result in a more normal body profile with smoother contours. It’s the last phase of a major weight loss program.