The patient in the before and after photos above lost almost two hundred pounds before seeking plastic surgery. I start here with this complex example because she has had three very common surgeries for a massive weight loss patient. She has had a Brachioplasty or arm lift, a mastopexy or breast lift, and a Fleur de lis Abdominoplasty or tummy tuck. This special kind of tummy tuck tightens skin both vertically and horizontally and is more common in the weight loss patient.
My weight loss patients are what I call works in progress. There is always something that needs tightening. The key to approaching my weight loss patients is to make a safe and common sense game plan. As we orchestrate multiple skin tightening procedures we want to make sure that we can do so in an orderly way so that one procedure does not take away the possibility of another. Multiple procedures can be performed at the same setting depending upon the patient’s health and the extent of the surgery. As a general rule I prefer to keep my patients out of the hospital. I plan surgeries that are reasonable and safe for outpatients.
After massive weight loss fat in the face disappears, the skin becomes loose and the neck and jowels can become more prominent. Facelift and other formas of facial rejuvenation can tighten the neck and jaw line.
Brachioplasty tightens loose skin of the arms after massive weight loss: There are different types of brachioplasty depending on the amount of skin laxity.
This patient had a full brachioplasy excising loose skin under the arms. The scars are hidden underneath. Brachioplasy removes skin and fat. Liposuction would have made this skin looser.
Extended brachioplasty removes loose skin beneath the armpit as well. This scar is about 6 months old. While clearly the scar is a trade off in this operation for patients who carry this much extra skin after massive weight loss it is a worthwhile trade.
Short scar Brachioplasty takes a wedge of skin out under the arms. It gives a limited amount of vertical pull and a subtle result.
This post partum woman lost almost 100 pounds. With weight loss the fat in the breasts can be lost as well and the breasts become droopy and saggy. This patient had a full mastopexy or breast lift. She also had a tummy tuck. While there are smaller kinds of breast lifts that can leave smaller scars, a full breast lift, as in this case tightens the skin the most and is most common after significant weight loss.
Tummy tuck Is often the first surgery that massive weigh loss patients entertain. As the abdominal fat decrease the skin can droop, hang, be uncomfortable and cause problems with hygiene. Extended and Fleur de lis tummy tucks are the most commonly used in massive weight loss because they remove the most extra skin. examples are shown below.
Extended tummy tuck is like a regular tummy tuck, but the scar goes very far back allowing more downward pull of the skin. This weight loss patient is loose all around the hips, so the scar follows all the way around to give maximal contouring.
This woman had a huge amount of laxity after weight loss. Her laxity is both up/down and side to side. A “fleur de lis” tummy tuck pictured below pulls skin downward and inward. I is generally only used for massive weight loss patients because of the vertical scar.
Some patients believe that plastic surgeons perform weight loss surgery. Plastic surgeons do not perform weight loss surgery. Plastic surgeons take care of the extra skin that is left behind after massive weight loss. General surgeons perform the surgeries that help people lose weight. The most common types of weight loss surgery is gastric bypass or the lap band procedure. Many patients lose their weight through diet and exercise. If I have a patient who is not having success with diet and exercise I will refer them to a surgical weight loss specialist to be evaluated. General considerations that I share with my weight loss patients:
1) It is always better to lose weight through diet and exercise. Turn to surgical weight loss if other reasonable attempts have failed. I am a fan of Jenny Craig, Weight Watchers, and Foodaddicts.com. I’ve had many patients with great success on these programs. I think their strength is that they relied not only on restricting calories, but they enjoy a healthy and balanced diet with behavior modification. In my opinion behavior modification is probably the most important part of weight loss. I also have a variety of nutritionists that help my patients as well.
2) Surgery such as the lap band which restricts your intake are better in my opinion because it is more like regular diet and exercise. Gastric bypass surgery while very successful with weight loss has more physiologic changes to your body which need to be considered at surgery. Patients still need good behavior modification because the lap band can fail by drinking high calorie liquids.
3) Patients who have had gastric bypass tend to be more depleted, and can have a higher risk of bleeding. We recommend a protein shake to our patients to enhance their metabolism and protein levels prior to surgery.
4) Even patients that lose weight through diet and exercise alone can have an increased risk of bleeding. When the tissues were larger the blood vessels became larger. After weight loss even though the fat is markedly gone the blood vessels do not shrink up as much.
5) It is best to be at the weight that you feel comfortable at before beginning skin tightening post weight loss procedures. If a patient is finding success with their weight loss I prefer not to rock the boat and jump in until they have gotten to where they want to be. Thinner patients tend to be better surgical risks and safer patients. Ideal weight does not necessarily mean rail thin, but it means realistic and sustainable weight. If the patient continues to lose weight after weight loss surgery they may require additional skin tightening. Most patients will embark upon post weight loss surgery when they are about 10 pounds from their target.
6) I prefer my patients to have had a period of stable weight before their surgery. If a patient is dieting up until the day of surgery their nutrition will not be sound and the risks of surgery increase.
7) Patients after massive weight loss with skin tightening surgeries may relax more than patients who have had modest weight gains such as the weight gain of pregnancy. Massive weight loss patients generally have a poor quality of skin compared to the average postpartum mother.
The risks for the surgeries are the same as for the surgery in non weight loss patients. But patients simply need to be managed as this group of patients can tend to relax more post surgically than the non weight loss patients. I thoroughly over the risks of the surgeries patients are considering in my consultations. The recovery really depends upon the degree and extent of surgery.
If you would like to meet with me to be evaluated for post weight loss surgery please call my assistant Pei (pronounced “pay”) at the numbers on the home page or fill out the contact form on the right. She would be happy to schedule a complimentary consultation.