The ins and outs of bariatric skin removal surgery

Bariatric surgery can be a very effective way for people who are obese and have failed at traditional weight loss tactics to lose large amounts of weight. When done in combination with a commitment to healthy lifestyle changes, it can be a life-changing and even life-saving process.

But it can also create another issue for recipients of the surgery: excess skin.

“Loose, saggy skin can be a functional problem,” said Matthew Ranzer, MD, FACS, a surgeon with OSF HealthCare who specializes in plastic surgery. “Your clothes don’t fit well, and skin rubbing can cause irritation, pain and discomfort. We can remove the excess skin, which is creating unwanted problems, and give you back your normal contour.”

People considering bariatric surgery and skin surgery should educate themselves before pursuing treatment options to make sure they handle their weight loss in a manner that is as safe as possible, to understand the requirements for success and to establish reasonable expectations for their results.

“Surgery is not a magic wand,” Dr. Ranzer said. “We cannot undue what has happened to your body from weight gain and weight loss. We can restore the normal contours of your body, but it requires surgery, which means risk and scars. Most patients do very well, and complications are infrequent, but they do occur.”

Getting started

The most important way to optimize patient safety and optimize outcome is to be as healthy as you can be prior to surgery.

Dr. Ranzer does not perform skin surgery until a person’s weight loss journey is complete, which typically takes about a year after surgery. He waits until the weight is stable and the person has a body mass index (BMI) of 34 or less.

“I will not do skin surgery on someone with a BMI higher than that because of increased risk of complications, and because I do my best job and get the best aesthetic results when I’m mostly removing skin, not skin and fat,” Dr. Ranzer said.

“There are two reasons we wait for stable weight,” he said. “One, if you’re still in the midst of weight loss, you can develop more saggy skin. Instead of doing multiple surgeries on the same area, I’d rather do one surgery the right way. The second reason is the way patients lose weight is by essentially being intentionally malnourished. So, the body needs to restore nutrition levels back to normal to aid in a proper recovery.”

You are not eligible for skin surgery if you use nicotine in any form because it increases the risk of complications.

Some of the procedures can be covered by insurance, but to get coverage you usually need to demonstrate functional impairment and that your attempts to manage the impairment with other methods were unsuccessful. A lot of insurance providers require a person to be at their plateau weight for at least six months before surgery.

And insurance still may not cover some parts of the procedure for some parts of the body. It may not cover moving your belly button or tightening of the belly muscles, and may only cover the removal of loose skin.

Common skin surgery procedures

In order of most common to less common:

1. Abdominal contouring – Removal of excess skin and tightening the muscles of the trunk. Sometimes this is for just the belly, but sometimes it includes the backside, too.
2. Breast reduction or breast lift – This procedure might involve augmentation to restore volume if the breasts appear deflated from weight loss.
3. Arm lifts and thigh lifts

Face lifts and neck lifts are the least common procedures because insurance providers consider them to be only for aesthetic purposes, so they’re never covered and not performed as often as the others due to the high costs of these cosmetic procedures.

What to expect

Once financial or insurance approval has been obtained, surgeries are done under general anesthesia and typically as an outpatient procedure, with the patient going home the same day.

“Typically we don’t do someone’s entire body in one surgery,” Dr. Ranzer said. “We will prioritize the area that bothers them the most and come back at a later date to do the next phase of surgery. If someone has loose skin on several parts of their body, they may need two to four surgeries over time to remove all excess skin.”

What else can a skin surgery patient expect from the process? Here are some insights from Dr. Ranzer about recovery:

• Typically for most procedures, the surgeon injects short and long acting numbing medicine so patients are comfortable after surgery.
• Depending on the nature of the surgery, you may have drainage tubes coming out of your body that get removed after one to three weeks.
• Half of patients will only need acetaminophen or ibuprofen to handle any pain after surgery, and the other half may need something prescription-strength for about a week.
• All patients are expected to be up and walking the day of surgery.
• Most are able to do normal activities like get dressed, cook, clean and go out of the house the same day as their surgery.
• Most are allowed to shower the day after surgery.
• Most find that within one to two weeks they feel comfortable sitting at a desk if they have a desk-type job.
• All patients are required to avoid lifting more than 10 pounds for about six weeks after surgery.
• Light duty restrictions can usually resume about two weeks after surgery.
• Most procedures require a post-operative compression garment to be worn for six weeks.

Risks

With any surgery there is the risk of stroke, blood clots, bleeding and infection. Being finished losing weight reduces those risks, so you need clearance from your primary care provider to help reduce risks to as little as possible.

The most common negative outcomes are asymmetries in the body shape if weight loss was not uniform, and scars associated with surgery. There is no way to remove skin without scarring, Dr. Ranzer said, so you’re trading sagging skin for scars, but improved body contours can be more beneficial than scars are negative. The danger with scars is that they can reopen and may require a second surgery to improve their appearance and strength.

“You have to commit to lifestyle changes,” Dr. Ranzer said. “There is no shortcut. You have to do it the right way or risk complications. I take care of a lot of patients who sought consultation for skin removal surgery without weight loss, went out of the country to find someone to do it and came back with life-threatening complications. Your health is not something you should take a risk on. You should do it the right way.”