Richard Baker Weekly Blog

Body Contouring in the Massive Weight Loss Patient

Massive weight loss is defined as when a person loses 50% or more of their excess body weight. For example, if a person weighs 100 kg but their ideal body weight would be 60 kg on the basis of their height, then their excess body weight is 40 kg and if they lost 20 kg or more, this would be massive weight loss.

Some people achieve this through diet and exercise and others through surgery, in particular gastric bypass, which is a very effective procedure and even cures type II diabetes. Inevitably, after losing a great deal of weight, there is excess skin which does not contract back down to its original size. This is because the skin is stretched beyond its elastic capacity; for example, an elastic band that is held outstretched for a long period will eventually lose its elastic recoil.

Unfortunately, it does not matter how much time elapses since the weight loss; the skin never regains the elasticity of normal skin. The skin also becomes much thinner. The excess skin tends to hang in folds and this causes problems with clothes, taking exercise, personal hygiene and affects people’s self-esteem and relationships. Therefore, removing this excess skin, so-called ‘body contouring’, is a very worthy endeavour.

The most frequently performed operation for this is an abdominoplasty or tummy tuck, often with a vertical scar in addition to the horizontal scar so as much skin can be removed as possible. However, in these patients the excess skin is often circumferential around the trunk and therefore a tummy tuck won’t be sufficient to address all the excess skin in the flanks and back. In these cases, the incision is taken all the way around to the back in a so-called ‘body lift’. This also helps to address some of the droopiness of the buttocks. Excess skin in the upper arms, so-called ‘bingo wings’, can be treated with excising the skin, leaving scars down the inside of the arms from the armpits to the elbows. In my experience, this procedure often has a higher satisfaction rate compared to the other body contouring procedures. The thighs can be treated in a similar way with a scar down the inside of the thighs, usually supplemented with liposuction. Breasts can be treated with a breast uplift or mastopexy but they often need some volume replacement with implants as the breasts do disproportionately lose their volume with massive weight loss and therefore simple excision of the skin does not restore them to their previous shape.

However, the challenge with all these procedures is the ongoing effects of gravity and ageing, the poor quality of the tissues left behind after surgery, some irreversible body shape changes and a degree of malnourishment that often accompanies a gastric bypass. The first of these problems, gravity, is unavoidable and relentless in its effects. It means that the tissues you have neatly suspended during surgery inevitably start to sag, meaning results of the surgery may deteriorate with time. This is most apparent in the breasts and the thighs. In the massive weight loss patient, the skin and ligaments have been overstretched and are less resistant to the stretching effect of gravity than the tissues of somebody with a normal weight – and that’s true even when the massive weight loss patient has returned to a normal weight. So, for example, the thighs can appear to regain some of their fat despite no change in body weight, and that is because some of the fat that was initially suspended high up on the inner thighs has gradually descended downwards. Breasts that are initially pert after a breast lift inevitably start to flatten and droop with time, but it occurs faster in a massive weight loss patient. Unfortunately, removing skin, say in a tummy tuck, does not mean that the remaining skin on the tummy gets thicker or loses its stretch marks. Thighs that have had the excess skin removed on the inside leg will not lose their cellulite because of the surgery. Ageing causes gradual thinning of the skin and fat accumulation whatever the person’s bodyweight and this natural change contributes to deterioration of the body contouring result over time. Malnourishment, particularly in terms of micronutrients such as vitamins, but also protein, may lead to problems with wound healing.

So what can be done to minimise the risks of body contouring surgery and maximise the benefits? Firstly, the person should have lost as much of their excess body weight as possible and have a stable body weight. The more fat has been lost, the more the skin will become loose and therefore the more can be removed. This obviously gives a better result. It is important the patient then maintains that body weight after surgery so that the result is not reversed. Body weight should be stable as this is a good indicator of sufficient nutrition. The diet should be healthy, and regular exercise should be undertaken as this will make the patient’s body better prepared for the rigours of surgery and also contribute to a better body shape through increased muscle mass. The surgeon and patient should be clear with each other about what can be achieved from surgery and that expectations are not unrealistic, i.e. the body contouring surgery will not give the patient the body they had before they put on the weight. Supportive garments should be worn after surgery to minimise the effects of gravity, in particular a supportive bra, but supportive elasticated garments throughout the body should ideally be worn as often as possible for the rest of the person’s life. Lastly, and most importantly in my view, I think the surgeon and patient should be aware of the fact the results are not permanent and that for results to be maintained, the surgery needs to be repeated. For example, however tight the tummy is after a tummy tuck, the skin inevitably relaxes, giving the appearance of regrowth of the skin, and so a repeat procedure is often necessary. I think if both patient and surgeon understand that from the start, then the outcomes are happier.

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