Individual Options: Post bariatric massive weight loss and body deformities
The epidemic of obesity in this country is contributing to millions of Americans developing diabetes, hypertension, heart disease, and worsening the outcomes of degenerative joint disease. Ultimately a true commitment to life style changes will lead to healthier outcomes. Some morbidly obese individuals need invasive bariatric surgery to aide in this endeavor and the results can be spectacular. Results including long lasting weight loss of sometimes two hundred pounds or more. Many times the unfortunate end result is individuals being held prisoner by their deflated, left-over skin that hangs from the breasts, arms, abdomen, flanks, and/or medial and lateral thighs. There is well documented literature which supports body contouring after weight loss in motivating patients to maintain their new life styles.
What are the options for body contouring after massive weight loss?
For the lower torso
Many patients initially fixate on the fact they have a large pannus of the abdomen (layman’s terms: apron or flap of tissue over the abdomen) and think all they need is to remove this isolated deformity. This is emphasized by bariatric surgeons who only feel comfortable offering panniculectomies (tissue/skin removal) for lower torso deformities because they do not possess the skills or have the aesthetic eye of a fully trained plastic surgeon. In fact many women and men complain that the lower pelvic tissue also hangs and has thinned and fallen away from the pubic bone leading to aesthetic deformities of the external genital region such as the mons pubis (layman’s terms: the area over the pubic bone) and vulvar region (layman’s terms: the area around the entrance to the vagina). Panniculectomies do not address this condition. Secondly the abdominal rectus muscles (the “Abs”) which act as an internal corset for the abdominal contents, holding them in check, often times become separated resulting in not a hernia but a large abdominal bulge. Women who have had children often will have a greater deformity than men. This also is never addressed during a panniculectomy. Another thing to consider: massive weight gain is not two dimensional therefore weight loss skin changes are also a three dimensional deformity. In addition to the abdomen and pelvic region, lower torso problems include excessive skin and fat hanging on the flanks, very proximal lateral excess thigh tissue, as well as the buttock becomes flat and shapeless making clothing difficult to wear. My recommendation for this constellation of deformities is the circumferential lower body lift. This is a single stage operation which includes a full lipo-abdominoplasty (removal of excess skin of the abdomen, correction of the underlying muscle deformity), pelvic rejuvenation (suspending and reshaping the mons pubis or the tissue surrounding the penile shaft), Flank tissue recontouring, lateral thigh resuspension, and lastly buttock reshaping and elevation with transposing excess tissue from the flanks to the buttock region. Yes this is a significant operation around six and a half hours but it is outpatient and our results are excellent and have never had to readmit anyone after surgery. This truly is a transformational operation freeing patients of their unwanted excess skin and all associated deformities and a very distinct difference from just a panniculectomy.
For patients who have already undergone a lower body lift and still have excess tissue in the upper abdomen that is loose a reverse abdominoplasty can be an ideal method to remove this excess and can be used to provide added vascularized tissue to add volume to the breast if an implant is not selected as part of a mastopexy.
Upper torso options
Just as there are many body shapes there are many variations to massive weight loss body changes. Both women and men experience deflation and hanging tissue from the upper arms and upper back region. The only way to correct this is through an aggressive skin reduction technique that commonly starts at the elbow and extends in a posterior medial line angle of the upper arm to the armpit and then continues on the posterior axillary line angle and follows the back as far down as required to remove the excess. In some women we can stop near the bra line. But our goal is to avoid hanging skin over the bra. Both men and women also have unsightly shapes to the chest and breast region. Women lose significant breast volume and have skin excess which leads to very flat deflated hanging breasts. In post-bariatric patients we try to avoid implants if we can because the residual soft tissue is generally not mechanically strong and holding implants in the correct position on a chest wall is quite difficult. I would prefer to perform breast lift with significant skin reduction and adding volume with either fat grafting or reverse abdominoplasties to obtain acceptable shapes. Sometimes I am forced to use implants but it increases the need for revision surgeries to get ideal results. Men often need gynecomastia (breast tissue removal) repair utilizing a significant skin reduction technique similar to a mastectomy and blending the scar into a chest fold. The standard gynecomastia techniques with PAL (power assisted lipectomy) with or without a periareolar (around the areola) mastopexy are not an option.
Once again there are many variations among patients and this region. I have seen men who have lost almost two hundred pounds and have near normal inner thighs. I have also seen women who are near ideal weight and have never lost any significant weight and have excess skin in this region. I will say I often see women who have cascading hanging skin of the inner thigh and upper knee area that prevent these people from feeling comfortable in shorts or skirts. Just as in the upper arms we aggressively liposuction the inner tissue and determine the skin excess and then remove this tissue blending it into the posterior and medial upper thigh and curving the incision into the groin crease. We purposely avoid anchoring the tissue superiorly to the ischium (curved bone forming the base of each half of the pelvis) to avoid deformities of the labia on women. Just as on the arm there is a scar but the vast improvement in contour out-weights the negative results of a scar.
Post-bariatric weight loss can be an amazing journey for patients allowing them to reclaim their health and happiness. Body recontouring is a necessary step to realize the freedom from the prison of excess skin left behind by the weight loss. Understanding that everyone unique, please come to the Lucas Center, Plastic Surgery to hear about our customized approach to restoring your confidence in yourself after weight loss.