FAQ

Losing a significant amount of weight is one of the most astonishing individual accomplishments because of the body’s innate physiological persistence in maintaining its weight. Whether achieved by diet and exercise alone or helped by a bariatric surgery, all of those who have lost a lot of weight expect – and deserve – to look much better. But after significant weight loss, there often remains significant redundant skin. Even fully clothed there can be a bulge from a stomach roll within the pants or rolling over the belt. It may still be embarrassing to wear a swimsuit or to become intimate for some people. Plastic surgery after this sort of weight loss can remove the extra skin and tighten and smooth the remaining skin to create dramatic improvements for these patients.

Arm skin has very little capacity for shrinking after weight loss. Even women who have never been overweight frequently will ask plastic surgeons about the skin of their arms. The lack of elasticity of arm skin is related to a combination of genetics as well as previous sun exposure. Some arm lifts only have short scars within the armpits.

Everyone wants a small scar that is hidden in clothing, but the amount of tightening is limited with this incision. The standard incision goes the length of the arm, from armpit to elbow, either on the inside of the arm or on the back of the arm. This provides the maximum amount of tightening. Sometimes it is combined with a scar in the armpit. The results of armlifts are dramatic and patients are thrilled with the outcome.

But the scar is significant and visible when the arms are not covered. This is a notable tradeoff and patients must decide that they will feel better with thinner arms and a scar than how they are now without a scar. Given the extraordinary improvement in arm contour, many women and men consider the scar very much worthwhile. Loose skin in the arm often joins up with the loose breast skin on the side of the chest, and a breast lift and arm lift are often combined.

The treatment of droopy breasts following massive weight loss is a breast lift. An implant is used if the patient also wants to be bigger. Though the procedures are technically the same, patients undergoing breast lifts and augmentations that have lost a lot of weight usually have greater amounts of skin excess. That means that the lifts need to have wider scars and need to be more aggressively done. Given how significant of a lift most of these people need, the lift and the implant are frequently split into two separate stages in order to be as aggressive, safe, and as accurate as possible. The skin is often more damaged meaning that there will be some tendency for the breasts to stretch a bit after the lift. Notwithstanding those issues, weight loss patients who have had breast lifts with or without breast implants are some of the most thrilled patients in Dr. Teitelbaum’s pratice.

One of the most satisfying surgeries after weight loss is having the folds of skin going across the upper back removed with a procedure called an upper back lift. The scar is usually well hidden within the bra strap. Beyond simply looking thinner, patients who have had upper back lifts will usually comment about enjoying a wider variety of clothing that looks good on them. Removing that roll also makes most people feel much more comfortable.

A tummy tuck is the gold standard treatment for laxity of the tummy. Extra skin can be removed and remaining skin tightened. Residual fat can be removed and recontoured. Some weight loss patients have hernias in their abdomens, and these can usually be repaired during a tummy tuck. Others have developed a rectus diastasis – a separation of muscles in the middle of the abdomen – and that can be fixed as well with a tummy tuck. Patients who have lost a lot of weight differ from the typical tummy tuck patient in two ways. First is that the looseness extends farther out to the sides and even to the backs, thereby requiring longer scars. The second issue is that their skin is often more damaged. Depending upon the severity, some crepiness or stretch marks may remain and the skin may not stay as taught for as long. This is obviously disappointing news. After all that work at losing weight it seems only fair to be able to have a totally taught stomach after plastic surgery, a stomach that will stay taught for many years. While this can occur, the inherent qualities of the skin obviously determine the final outcome.

The tummy tuck will take care of skin in the front. But rolls around the love handles and into the back cannot be treated with a tummy tuck alone. There are two ways to deal with this. The first is to do a a so called "belt-lipectomy," which continues the tummy tuck scar all the way around the waist and smooth out the skin of the love handles and lower back.. A lower body lift, also known as a thigh/buttock lift, combines a tummy tuck with a procedure that lifts the outer thighs and the buttocks.

A thigh/buttock lift is also known as a lower body lift. With weight loss there is often deflation and sagging of the buttock. There can be looseness on the outer thighs and the front of the thighs. The lower body lift has a tummy tuck component which is no different than a standard tummy tuck. But the incision then extends all the way around the back. The surgeon focuses attention on the buttocks and outer thighs and lifts them to a higher and better position, reducing the amount of looseness in those areas. The buttocks are often so deflated from weight loss that even the buttock lift does not make them perfect, but the improvement is significant. The thigh component works for the front of the thighs and the outer thighs. Most of the improvement a body lift gives to the thighs is in the upper third of the thighs, but the improvement can go quite a ways down toward the knees, but not all the way. The lower body lift does not help the skin of the inner thighs; for that an inner thigh lift is done. The most common approach involves an incision in the inner groin crease. This can tighten just the highest bit of loose tissue in the inner thighs. If the inner thighs are loose most of the way down toward the knees, then the only procedure is a thigh lift with a vertical scar that is the whole length of the thighs and placed along the inner thigh. While the scar is certainly dramatic, so too is the improvement. Like all plastic surgery patients having weight loss surgery, the critical issue each patient needs to answer for themselves is how much improvement justifies the scar.

There are timeless rumors about plastic surgery: Cher getting a rib removed and Demi Moore having a knee lift. I’m sure no one would be disappointed to hear that there is no cosmetic procedure that involves removing a rib to narrow a waist. But the sad truth is that there is as yet no knee lift surgery. Putting any incision across the knee would look horrible. No laser or other energy device is as yet effective at tightening knee skin. In extreme cases of total leg laxity a long incision can be made along the inner thigh to tighten the entire thigh, but this isn’t really a knee lift. Even a total lower body lift or a thigh lift only causes minimal changes to the loose skin above the knee. If there is a bulge of fat on the inner knee or just above the knee liposuction can be done to remove the bulge, though that’s rarely a primary issue in someone who has lost a significant amount of weight. It’s sad but true that there is little to be done to significantly improve the knees.

There are no steadfast answers about how much is safe to be done at the same time. It depends upon the exact combination of procedures, the height, weight, and physical condition of the patient, how significant of a problem each is and the procedure it requires, and even the opinion of the surgeon. Some surgeons are more aggressive about combining large numbers of these problems, while others believe it is more prudent to separate them. Dr. Teitelbaum sometimes combines many procedures, but in general terms he more frequently favors splitting up procedures because he always makes safety his first priority, and believes that results are better when the entire operating room team is focused about delivering the maximal result on fewer areas at a time.

The procedures for the patients who have lost the most weight are among the largest procedures aesthetic plastic surgeons do, involving the most operating room time, suturing, and recovery. Some of these patients have poor skin quality, either because it is thin, irritated, or contaminated with bacteria under skin folds or in parts of the body that are difficult to clean. There is therefore an increased risk of infection and wound separation as compared to the typical plastic surgery procedure. Patients need to be prepared ahead of time that these problems can occur up to 20% of the time so they are not rare. And while usually a mere nuisance, these problems can also be very significant, delaying recovery, causing the patient to incur additional expenses, requiring a future revision, etc. But even with those problems, the results are so unbelievably good that patients still are thrilled they underwent the procedure.