A Happy Loss

The much-publicized dramatic dropping of pounds exemplified by high-profile personalities like Al Roker, Roseanne Barr, Carnie Wilson and others is bringing bariatric-or weight-loss-surgical techniques into the mainstream.

The number of bariatric procedures (meant for the morbidly obese) has jumped from 67,000 in 2002 to an estimated 144,000 this year, according to the American Society of Plastic Surgeons. But while gastric bypass and gastric banding (stomach stapling) can lead to dramatic weight loss, many patients still aren't satisfied with their bodies after the extra pounds are gone.

"All of a sudden their skin doesn't fit them anymore," says plastic surgeon Dr. Andrea Basile of Naples Breast and Body Surgery. "These people are only halfway there." Many plastic surgeons here are getting more inquiries from patients about body contouring, the catch-all name for procedures to tighten loose skin left behind after significant weight loss. The most common of these are abdominoplasty, or tummy tuck, and surgery on the arms and thighs. But procedures may also include breast or buttock lifts, and face and neck procedures.

"Even if weight is lost gradually, skin doesn't stretch back," says Naples-based plastic surgeon Dr. Manuel Peña. Besides excess skin left behind after extreme weight loss, skin elasticity can also be compromised by sun damage, smoking and aging. And working out won't usually solve the problem. "You can't exercise the skin," Peña adds.

Dr. Bill Eshbaugh of South Florida Plastic Surgery in Bonita Springs agrees: "For the extreme conditions we're talking about, there's no other alternative to deal with that excess skin than surgical procedures."

There are risks, expenses and limitations involved with this type of post-bariatric plastic surgery. Eligible patients should arm themselves with information before determining when-and whether-to undergo body contouring procedures.

Almost all surgeons who perform body contouring want to make sure prospective patients have reached a stable plateau of weight loss before considering the procedures-generally 12 to 18 months after bariatric surgery, or when a person has maintained a steady weight for six to eight months. Otherwise, the skin may simply become loose again if weight continues to be shed. In fact, some small gain in weight can be positive, says Peña. "I always expect a little rebound, and actually it looks a little bit better," he says, as the newly taut skin is filled out slightly.

The wait also gives patients time to recover from the initial surgery and achieve optimum health. Depending on which type and how many of the body contouring procedures a patient elects to undergo, the entire plastic surgery process may take about a year, including recovery time between procedures.

Cigarette smoking is a very high-risk factor for plastic-surgery patients. The nicotine and carbon monoxide reduce oxygen and blood flow to the skin, impeding recovery. "The biggest thing smokers can do to help their skin is to stop smoking," says Eshbaugh.

Most surgeons leave the order of surgeries up to the patient, who can determine his or her own most distressing problem areas. Many patients begin with abdominoplasty to address the apron of skin often left hanging over the beltline after dramatic weight loss. More involved versions of this procedure can even extend all the way to the back to address love handles, hips and buttocks.

Some patients may begin with a thigh or arm lift, since the thinner skin there can be "notoriously looser than for other areas," says Dr. Mark Prysi of Prysi Cosmetic Surgery in Naples.

No matter the order, however, the surgeries require a commitment of time, money and maintenance. "They're significant surgeries. You have to have a motivated patient," says Prysi.

Most insurance companies do not cover the costs of body-contouring surgery, though that may change because of Medicare's recent classification of obesity as a disease. Meanwhile, patients can run up a hefty tab, with costs for multiple procedures ranging from $20,000 to more than $50,000. Yet doctors have found that most patients find the investment worthwhile.

Another factor for patients to consider: scarring. Though surgery in certain areas leaves minimal, unobtrusive scars, with other types of procedures scarring is more prominent. With arm and thigh lifts, for example, attempts are made to conceal the scars mostly under the arms or inside the thighs. But "some parts are quite visible," says Basile.

"At this point, I'm less of a magician and more of a tailor," says Peña. Doctors make every effort to minimize scarring, and techniques are constantly improving. Still, patients must accept some scarring if they choose these procedures. "It's not that unusual to have scar revision as a minor procedure down the road," says Eshbaugh.

Doctors encourage patients to research the risks, benefits, costs and other considerations, and to discuss them with their surgeons. Patients who feel their initial weight gain was a result of deeper issues might also seek psychological help to give them one more weapon in their arsenal to maintain the results for which they've worked so hard.

Basile says it's rewarding to help these patients. "They're just amazed at the thin them that's underneath all this," he says.

"It's one of the most satisfying procedures," says Eshbaugh.