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Reshaping You to Fit Your New Body

A growing epidemic in the United States is morbid obesity.

Be it genetic predisposition, poor eating habits, a sedentary lifestyle or post partum weight gain, the US and the world is realizing the medical costs associated with this epidemic. Already, the statistics are staggering. Forty percent of the population is obese and increasing every year.

For the longest time morbid obesity was treated non-surgically. Weight reduction was usually tied to exercise and calorie controlled diets. Medically, physicians were able to help by correcting imbalances in hormone status such as thyroid, estrogen, and cortisol. Anti-obesity

drugs such as phentarmine have also played a role, but their long term side effects are still questionable and cost is a factor. But as obesity skyrocketed, so has diabetes.

About 15 years ago, a surgical option was developed for the very morbidly obese and was reserved for those in life and death situations. Although complications were relatively high, it was the beginning stages to developing the protocols for surgical weight loss procedures that we are accustomed to today.

Weight loss surgeries today consist of either lap bands or gastric bypass. These procedures have proven very successful in extreme weight loss for the morbidly obese and has been maintained over a longer period of time than

most non-surgical entities. In fact, according to the Agency for Healthcare Research and Quality, bariatric surgeries have increased nine-fold between 1998 and 2004 from 13,386 to 121,055. Complication rates have also decreased due to laparascopic techniques.

While significant weight loss may look successful on the outside, it leaves another side that is largely not talked about – excess and sagging skin.

When consulting for bariatric surgery, the potential for body reconstruction should always be addressed. A lot of physicians and patients assume that once the weight loss is done, the patient will go back to their perceived new looks without any corrective surgery. As a plastic surgeon who performs post-bariatric cosmetic surgeries, almost 95% of patients require some reconstructive work approximately one to two years after their surgery.

A lot of patients don’t realize that with morbid obesity the skin, fascia and underlying tissue support system is strained and damaged to the point that it loses its recoil abilities. Very few people will have their skin go back to normal.

Think about pregnancy and how the abdominal skin does not return 100 percent to its pre-pregnancy state. Now, use this same analogy and put it to skin on the entire body for a much longer period of time. You can realize the extent of the damage to the skin and underlying tissue.

Our skin, breasts, and underlying tissues are soft, pliable and somewhat durable. But our bodies were never made strong enough to handle excessive weight over a long period of time.

So where do we start?

In the face, one usually sees the tell tale signs of aging: redundant skin in the face, neck and eyes; fatty deposits in the neck and eyes; early jowling; thinner skin; exaggerated facial lines (nasal labial folds). These are usually taken care of with brow lifts, eyelifts, face and neck lifts and fillers such as fat, Restylane or Radiesse.

Also common after weight loss is hair loss. This can be taken care of medically or sometimes surgically with micro or macro hair graft transplantation.

The chest and breast area usually does not fair well after extreme weight loss. The breast support system is made of skin, connective tissue and ligaments. Unfortunately, these specific tissues don’t hold up well to excess weight over long periods of time. As the weight loss is complete, the breasts tend to lose a lot of their volume, shape and support. They decrease in size and become ptotic (droopy).

Treatment options may include a breast lift, augmentation or oftentimes both. Thanks to newer techniques in minimally invasive surgery (PEBAM, SPAIR) scarring is left to a minimum while the saline or silicone implants can increase the breast’s volume.

The arms also suffer from redundant skin. The skin in the inner aspect of the arm is the thinnest compared to the outer arm. Some of the redundant skin involves the axilla and upper back area. The excessive skin is usually excised and the upper arm reconstructed to give a more natural look. This is known as a brachioplasty.

Liposuction is also used as an adjuvent in certain areas. The scar heals up somewhat well and is located on the inside of the arm extending into the axilla. If the upper back has redundant skin, an upper body lift is considered to get a more cosmetic appearance.

The areas most people complain about is the abdomen and thighs. In the abdominal area, the skin may be loose and overhanging their beltline, there could be some fatty deposits that are not desirable, and the muscles may be weak and need to be tightened. Also, hernias resulting from the gastric bypass may be present. The best way to take care of the abdominal area is either liposuction, abdominoplasty, or both.

In the thighs, the skin becomes redundant and sags both in the inner and outer areas. The buttocks can also lose their volume and sag. An inner and outer thigh lift is usually done in conjunction with a buttock lift. This can involve liposuction to contour the thighs. The abdominoplasty, inner and outer thigh lift, and buttock lifts are collectively known as a lower body lift. The scars are acceptable and usually hidden in creases or the underwear line.

Liposuction alone is not enough to give the body the contouring that is most pleasing. It is an adjunct only. Surgical scars usually take a year to heal and in about 10 percent of patients, revisions may be necessary. Like all surgeries, the risk of complications is greater in the post bariatric population. A thorough medical clearance is advisable, and peri-operative antibiotics and DVT prophylaxis is given.

The big question is how much of this surgery should be performed at a single setting? There is no right answer. However, scientific studies show that the longer in surgery you are, the more at risk you are to suffer afterwards (pneumnia, DVT, Pulmonary emboli, atelactasis, etc.).

The general rule of thumb is usually six hours. My philosophy is to stage the surgeries over a three month period, doing no more then 6-8 hours at a time. Remember, it’s not how fast you get to the finish line. It is getting there in the safest fashion.

In the end, realistic expectations and safe and effective reconstruction by a board certified plastic surgeon can help you get over the stigma and the resultant excess skin left. Leaving behind, a new you!

Ayoub Sayeg, M.D. is a Board Certified Diplomate, American Board of Plastic Surgery, Cosmetic and Breast Fellowship Trained. He received his medical degree from the University of Toronto and served his general surgery residency at Washington Hospital Center, Washington, D. C. Dr. Sayeg served his plastic surgery residency at Wayne State University in Detroit from 1998 to 2000.