Post-Bariatric (Massive Weight Loss)

This is an important procedure to which I wanted to dedicate an entire section of the website. There are so many patients seeking this procedure that plastic surgery for massive weight loss has quickly become a subspecialty in its own right.

There is a lot of information specific to these patients and their procedures that should be discussed. I am sympathetic to the fact that many patients with excess folds of skin after massive weight loss still consider themselves fat. I very much understand the needs and concerns of these patients; you are well on your way to resuming normal size and a normal life, but you’re hindered by the outcome of many lost pounds. I am pleased to be able to help you with this issue.

Many patients nowadays have undergone bariatric surgery, that is, bypass or stapling of the stomach. It has become a very safe and predictable operation well tolerated by patients of virtually any large size. The result of this is a large population of individuals with significantly sized rolls of excess loose skin all over their bodies. The essentials of your anatomy that we are dealing with are loss of skin elasticity, poor skin quality (stretch marks), and excess skin because the underlying fatty support framework has been deflated. Furthermore, the skin cannot totally contract back down enough because it has lost its elastic qualities. The underlying muscles and bones are fine. There is laxity in the ligaments that course from the muscles to the skin to support these areas. The relationship between the amount of excess skin, skin elasticity, vectors of laxity, and excess fat is what determines the surgical intervention. I will coordinate the features of your anatomy with your expectations, formulate a plan with you, and guide you through this process.

After bariatric surgery it is best to wait until your weight has stabilized. Plastic surgery for treatment of the excess skin can be done in STAGES; less often it may all be done at one time, depending on the anatomy, your medical condition, and your expectations. The surgery involves making incisions in concealed areas, such as in the underwear lines; however, it is often best to coordinate placement of these incisions with the vectors of greatest laxity. This is how you get the best pull and the best result. To determine your vectors of laxity, use the “pinch test”; pinch up your excess tissue and pull as much as you can to get the maximum result. Where you pinch up the skin is at or near where we should place your incision. Working through the incision I then create a space to loosen any retaining ligaments, tighten underlying muscles as indicated, pull the edges together at just the right tension, trim the excess, and close up the incisions. Some residual fat may need liposuction in certain areas. Deep stitches are secured to the ligaments and bone, so there is less of a tendency for the skin to fall down. The length of the incision depends on the amount of excess skin removed, and it is not unusual to remove five to ten inches in length! In general please remember that “THE LONGER THE SCAR, THE BETTER THE RESULT.” Implants are often used in association with a breast lift. The healed incisions are usually pencil thin and are located relative to your areas of excess skin and the greatest laxity. Incisions may have a tendency to heal slightly wide and dark, but this gets better over time. The surgery is mostly comfortable because it is essentially a surface surgery, and I do not cut through things that hurt like muscles, tendon, and bone. Surgery involves a general anesthetic and an overnight stay in the hospital and is performed where I do surgery, which is in a hospital setting with an MD anesthesiologist. The surgery is safe and predictable. There is some pain and swelling after surgery, but this is not severe or prolonged. The stitches are all dissolvable, and you can return to activity and some work in as little as ten to fourteen days and to some physical exercise in the third week. Surgeries to revise and “touch up” previous procedures are very common.

The surgical procedure and results of a body lift depend on your anatomy, the number of areas involved, the amount of excess skin, and vectors of laxity. Collectively, these features all determine where the incisions need be made, how long the incisions will be, how much tissue will be removed, and whether this surgery can be done in one multiple stages.

The categories of surgery for massive weight loss that I offer my patients may be thought of in terms of the following spectrum of possible procedures:

• Body Lift: (See our Body Lift section, as this is the main concern to patients in weight-loss surgery. This is the usual approach to the trunk and torso. It may be combined with one or more of the following surgeries.
• Outer Thigh Lift: This is a case in which the abdomen and buttocks are mostly okay, and a lift to just the outer thighs is needed. The incision is some length along the belt area of the outer thigh.
• Inner Thigh Lift: Same as above, as applies to the inner thigh.
• Tummy Tuck: (Abdominoplasty). This may be done alone or in stages combined with a body lift. (See the separate Tummy Tuck section for further information.
• Butt Lift: This can be done alone or as part of the staging, and involves an incision in the belt area just in the back and partway around the sides.
• Breast Lift with Implants: Many patients wish to combine this with other body contouring procedures.
• Arm Lift: (See the separate Arm Lift section).
• Chest Wall Lift: Incisions are made along the bra line from the breast around the back to remove these rolls of skin when present.
• Facelift: This is often requested by patients with excess facial skin and a loss of elasticity.

I have great expertise in body lifting procedures, and I have performed many of these operations over the years with very natural results. I spend a great deal of time discussing your anatomy, listening to your expectations, and interpreting for you what your anatomy and tissues will safely and predictably allow me to do. In addition I consider your body as a whole, and I build a system into all body-contouring surgeries that, initially, allows you to recover much more quickly and, secondly, preserves your surgical results. This system includes a special diet, special attention to blood clotting, vitamins, supplements, special garments, skin products, physical training, and knowing what to avoid. Together all of this allows me to create results that are consistently very beautiful, quick to heal, and exceptionally natural. I use minimal incisions. I am delighted to surgically provide you with such a profound yet natural body-image change, one that has so consistently pleased my patients and changed their lives.

We recommend that you review Dr. Romano’s article on body contouring in the Educational Articles section of the website.