The Skinny on Post-Bariatric Plastic Surgery

Marisa Lawrence, MD

Article by
Atlanta Plastic Surgeon

1. What happens to a patient’s body after massive weight loss?

Post-bariatric plastic surgery is a major growth field today as a direct result of the increasing incidence of bariatric surgery performed in the United States.
While massive weight loss following bariatric surgery improves a patient’s health and quality of life, it also leaves hanging excess skin folds throughout the entire body.

This extra skin can lead to patient dissatisfaction with appearance, inability to exercise, impaired ambulation, difficulty with hygiene, persistent skin infections known as intertrigo, as well as contribute to the persistence of a negative body image and poor self-esteem over time.

Through a number of operations collectively known as “body contouring,” surgeons are able to restore their patients’ bodies to a more normal look, and improve health and confidence.

2. What does “body contouring” entail?

Body contouring is the surgical reshaping of the body. It can involve removal of excess skin, removal of fat, and repositioning of tissues to form a better contour.
Some contouring procedures leave only small inconspicuous scars. More noticeable scars may result when surgical removal of skin and fat is necessary to achieve the desired result. Most patients find these scars acceptable and enjoy greater self confidence when wearing a bathing suit or form fitting clothes.

3. Why do patients choose to have plastic surgery after massive weight loss?

Massive weight loss achieved by either bariatric surgery or diet and exercise can greatly improve both the physical and mental health of patients. However, the physical limitations associated with the excess skin can adversely effect their quality of life. Most of the patients who have lost massive amount of weight have made dramatic changes in their lives and for many of them getting rid of this daily reminder of the person that they used to be is a very high priority.

A persistently poor body image despite the patient’s enormous accomplishment with successful weight loss remains a significant issue. Diet and exercise will maintain weight loss but it will not reduce the amount of hanging skin. Body contouring procedures, in a properly selected group of patients, can be immeasurably rewarding to the patient as well as the plastic surgeon.

4. What plastic surgery procedures are usually performed in post-bariatric surgery patients?

Patients are usually surprised to learn the extent of plastic that is required to bring their body back to a more normal and aesthetic appearance. Deformities associated with massive weight loss vary greatly depending on the patient’s body type, their fat deposition pattern and the amount of weight gained or lost.

Symptomatic sagging skin typically develops around the face, neck, upper arms, breast, abdomen, buttocks and thighs.

After dramatic weight loss the face skin can become flaccid, resulting in the cheek pads drooping and jowls forming resulting in the loss of a defined jaw line. The neck also becomes loose and sagging. Some of my patients describe it as their “turkey gobbler” neck.

A face and neck lift raises the cheeks pads, corrects the jowls and removes the loose and sagging skin of the face and neck. The incisions are very inconspicuous, placed around the ears and in the hairline. This procedure can be performed as an outpatient and recovery is usually 5-7 days .

There are various surgical procedures available to treat upper arm laxity, described as “batwings” by my patients. The brachioplasty technique varies depending upon the upper arm deformity and may include liposuction, short scar brachioplasty and long-axis arm incision with axillary Z-plasty. Regardless of the technique, scar placement is a high priority and requires the skill of an experienced plastic surgeon.
Abdominoplasty involves the removal of excess skin and fat from the pubis to the umbilicus and includes abdominalmuscle tightening and repositioning of the umbilicus as well as elevation of the pubis. A panniculectomy involves the removal of the hanging skin only and does not involve muscle tightening or umbilical repositioning.

A panniculectomy or abdominoplasty alone will eliminate the large hanging abdominal pannus and its symptoms but may leave redundant tissue known as “dog ears” posterior to the incision. Circumferential approaches such as the belt lipectomy provide a superior aesthetic result because the anterior deformities as well as back and side rolls are addressed and the buttocks is lifted.

A belt lipectomy is a circumferential procedure which combines the elements of an abdominoplasty or panniculectomy with removal of excess skin and fat from the lateral thighs and buttock. The procedure involves removing a belt of tissue from around the circumference of the lower trunk which eliminates lower back rolls, and provides some elevation of the outer thighs, buttocks and pubis. This procedure is also known as a circumferential lipectomy and a lower body lift.

Excess hanging breast tissue is usually treated with a breast lift or mastopexy, although some patients may requires removal of breast volume with a breast reduction. Implant placement may also be performed to improve the shape of the breasts.

Removal of excess thigh skin and fat may include liposuction and/ or a formal thighplasty with longitudinal and groin incisions. Staged procedures may be required for the best results.

Patients need to realize that to re contour and shape the body after weight loss there will be visible scars. While the results of the body contouring are visible immediately, scarring is permanent and it may take 1-2 years for the scars to flatten and fade. Still, post bariatric body contouring procedures are associated with high rates of patient satisfaction.

5. When is it advised to have plastic surgery following post-bariatric weight loss?

Timing for plastic surgery after undergoing bariatric surgery is very important. Plastic surgery is not a substitute for weight loss. For the best results, patients need to be at their goal weight and to have maintained that goal weight for 3 months or longer. Following bariatric surgery, weight loss is rapid during the first three months and decreases exponentially afterwards, stabilizing after a period of 15-18 months.

6. How is the skin of someone who has lost a lot of weight different from the skin of a normal weight person?

The skin of someone who has lost a lot of weight is less elastic than the skin of a normal weight person. The skin is permanently damaged from being stretched to such an extreme. It has lost its ability to maintain tightness and tone. Even though we can make the skin fit the body again through plastic surgery these patients skin will loosen over time much faster than patients with unstretched skin. New technology with the use of laser-assisted lipolysis may be beneficial in maintaining skin tightening.

7. Can all the procedures be done in one operation?

The staging of multiple procedures is determined by both the judgment of the surgeon and the health of the patient.

Although single stage procedures offer the patient the advantages of decreasing cost, facilitating time off work and one induction of general anesthesia, prolonged operative times can involve substantial blood loss and fluid shifts creating greater physiologic stress than even the bariatric procedure.

Although there have been no definitive reports on the subject, it is generally recommended that the surgeon limit operative time to no more than 6-7 hours and stage the subsequent procedures at least three months apart.

8. What can patients do to improve their results with plastic surgery?

Patients who are considering body contouring procedures should be aware that these are major surgical procedures. Massive weight loss patients may be at increased risk for complications secondary to potential nutritional deficiencies, leg varicosities and poor quality elastic tissue.

Literature review of 80 relevant articles identified these factors as contributing to a successful surgical outcome:

  • Completion and stabilization of weight loss
  • BMI<32
  • Smoking cessation
  • Nutirtional assessment
  • Anemia correction
  • Prophylaxis against thromboembolism

Patients who are considering body contouring surgery can do several things to improve their results with plastic surgery. Again, weight loss should be complete and stabilized. Body mass index should ideally be less than 32. Patients should be nonsmokers. Smokers need to quit at least 6 weeks before surgery and not resume smoking after surgery. Long-term nutrient deficiencies are not uncommon for bariatric surgery patients. Protein, calcium, vitamin D, vitamin B12 and iron are the most common deficiencies requiring correction before surgery.

Patients should arrange to have friends and family available to assist them during their recovery process. Most body contouring procedures are in fact major surgical procedures and patients need to allow adequate time to recover from these operations. That can range on average between two and four weeks, although patients who do heavy lifting on their jobs may need a little bit more time.