Massive weight loss is a common thing these days. People are losing weight dramatically sometimes more than 50% of their body weight. This is scientifically defined as “massive weight loss”. There are many weight reduction methods such as dieting, lifestyle changes, over the counter pills, paranormal ways such as bulimia and bariatric surgery.
Even after losing a large amount of weight, simply being within normal range is insufficient for most people. They want look as attractive and as normal as possible.
Often after massive weight loss, people end up having loose and saggy skin, lax muscles, oddly shaped protuberances, vestiges of fatty tissue (bags containing fatty acids and triglycerides) remain in form of flabs and unexpected folds, pleats, puckers and creases. [Reference- An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Shermak MA, Chang D, Magnuson TH, Schweitzer MA Plast Reconstr Surg. 2006 Sep 15; 118(4):1026-31.]
According to Pittsburgh rating scale there are ten anatomical areas that undergo maximum changes after excessive weight loss-
- Mons pubis
- Inner thighs
- Hips and lateral thighs
- Lower thighs and knees
In my opinion there are two other areas that get significantly affected face and neck and hair loss.
The deformities range from
- Grade 0 meaning appearance is within normal range.
- Grade 1 is mild deformity that may require some minimal invasive procedure
- Grade 2 is moderate deformity that often requires correctional surgery and
- Grade 3 is severe deformity that requires multiple procedures.
What happens when you lose weight quickly?
Weight loss not only causes loss in volume but it has detrimental effect on skin collagen that reduces the elasticity and quality of skin. What that means is when you stretch the skin normally it recoils back immediately, but when elastin and collagen is reduced the skin does not recoil back and keeps stretching as you keep pulling it.
How to Lose Weight Correctly?
I always recommend my patients to gradually loose weight and ensure that they eat healthy nutrition with supplements to ensure the skin and hair integrity are significantly affected. I also recommend to do muscle building exercises because as you loose fat and volume the skin sags, but if that volume is compensated by muscles to some extent the skin will drape back.
Men have advantage as they can build up muscles and beef up in the chest, arms, back and thighs thus firming up the skin. The only problem area that remains are abdomen, face and neck because you cannot beef up the muscles in these areas.
Women have more challenges; they cannot beef up significantly to prevent masculinization. Yet I do recommend them to build muscles in chest, back, arms and thighs.
What happens after massive weight loss?
Let me explain what happens after excessive weight loss in different regions of the body.
- Face and Neck: Due to weight gain fat cells increases in face and neck and stretches the skin but as you loose weight the volume reduces and skin starts sagging. The face may appear gaunter and emaciated and neck develops loose skin folds like “turkey neck”.
- Chest in Men: Men develops a condition called pseudogynaecomastia where the skin sags along with residual fat bags and gives an appearance of man breasts.
- Breasts: There is extensive thinning of breasts and sagging and they develop loose folds in bra roll areas.
- Abdomen: Both in men and women form folds and rolls of skin in the tummy region sometimes one or two and in many cases three rolls. The skin is not only saggy in vertical direction but they have excess skin in horizontal direction. Often the underlying muscle is also stretched out and weak.
- Mons Pubis: There is significant changes in mons region with hanging skin, droopy genitals, buried penis etc.
- Back and Buttocks: Multiple rolls develop in the back region and the buttock sags with wrinkling and distortion of the shape. Hip fat and skin forms rolls and folds laterally.
- Thighs and knees: excess skin develops in thighs in both directions circumferentially and vertically causing sagging, skin folds, cellulites and abnormal protuberances. The kneecap disappears due to skin folds over the knees.
- Arms: likewise develops flabs like “bat wings” and skin folds develop above the elbows.
Body Contouring Surgery and Body Lift Surgery
Body contouring surgery involves removal of loose skin and residual fat bags along with suspension of skin.
The wide breadth and variety of deformities means surgical options are also endless. If one has to address each and every problem than one may have to go through the following list of surgeries.
- Face and Neck lift with or without fat grafting
- Breast lift with or without implants
- Tummy tuck- only conventional or T shaped abdominoplasty also called as “Fleur De Lyse”
- Brachioplasty- vertical and or horizontal
- Lateral chest lift or axillary lift
- Back lift
- Buttock lift
- Thigh lift- vertical and or horizontal
- Knee lift
- Male breast lift
This is an exhausting list of surgeries to correct all most of the problems. But surgeries come with a cost not only financial burden but trauma, pain, scars, risks and side effects.
Over past 25 years I have integrated some refinements and combinations of procedures that is safer and has better long-term results.
I thoroughly counsel the patients followed by complete tests and examinations to ensure their fitness for surgeries. I help make a plan for the patients with various permutations and combinations of the surgeries.
My recommendations begin with following advice:
- Work hard to replace some volume by building muscles.
- Ensure you have stabilized your weight and health with good nutrition and regular exercises.
- It is not possible to chase all the loose skin
- Goal is to minimize number of scars and number of surgeries
- There is a limitation on number of surgeries that can be performed in one person.
- Time is essence to minimize risks and complications, so my goal is to limit surgeries to 4-5 hours. Less time of anesthesia means better recovery and minimal complications.
- Although the skin appears very tight immediately after the surgery but depending upon your collagen it will loosen up in 5-6 months time. There is a thin line between over tightening of skin and wound breakdown or scar stretching and migration.
Preoperative assessment before a Body Lift Surgery
I prefer to do a complete medical checkup with blood tests to minimize risks and complications. The key tests include bleeding and coagulation profile, protein and haemoglobin level and kidney and liver function tests. An ECG and X ray chest may be necessary in patients above 40 years of age, chronic smokers and other comorbid conditions.
A well controlled diabetes mellitus and or hypertension is not a contraindication for surgeries.
Planning of Body lift Surgery
The commonest procedure people need after massive weight loss is Abdominoplasty or tummy tuck and breast/chest lift in male or female.
Abdominoplasty can be an extended abdominoplasty with incision from one hip bone to the other or a circumferential body lift with incision going around to the back also called a Belt Lipectomy. This procedure allows some extent of buttock lift as well.
Very few people may need a combination of vertical and horizontal tummy tuck called as “Fleur De Lyse” abdominoplasty however the vertical scar is not a very pleasing scar and I recommend only for people who has very unsightly abdomen with huge excess skin, than scar is not a big deal.
If I am doing a buttock lift, I recommend “autoaugmentation gluteal lift” which means I will use the fatty tissue around the buttock area to augment and give volume to the buttocks. [Ref- Hunstad JP, Repta R. Purse-string gluteoplasty. Plast Reconstr Surg. 2009;123:123e–125e.]
Augmentation Mastopexy is a procedure that combines use of breast implant along with lift and skin tightening of the breasts. Very few patients may get away with just a breast lift if they have good volume or they choose not to have any implants. The preferred breast lift technique is anchor shaped to give a good long-lasting lift.
Arm sagging is the next common area of concern mostly in female patients. Brachioplasty is a arm lift procedure and it can be done as a vertical only or “T” or “L” shaped brachioplasty. I prefer to keep the scar at the seam of the arm so it is less visible from front and back and can be seen if patient lifts her arms.
I use “J Plasma” from Bovie Company to further tighten the skin internally. It is a new technology that is now used in combination with Vaser during liposuction to improve the collagen in the skin.
Thigh lift is necessary in patients with excessive sagging thighs. The ideal technique is “T” thigh lift that addresses removal of excess circumferential skin and also lifts the thigh upper in the groin crease areas. In some patients doing limited thigh lift in combination with Liposuction and J plasma skin tightening can minimize the scars.
Face and Neck Lift is rarely necessary in patients as there are many nonsurgical and minimal invasive options to firm up the skin in face and neck. Ultherapy lift, Thread lift, filler injections and fat grafting are some procedures that helps improvement of face and neck skin.
The combination of procedure depends upon the priority given by patients, the severity of the problem, medical fitness, duration of surgery and recovery period available for the patients.
My recommended combinations are-
- Lipoabdominoplasty with lateral thigh lift
- Circumferential abdominoplasty with buttock lift
- Lipoabdominoplasty with breast lift/ augmentation mastopexy
- Lipoabdominoplasty with brachioplasty
- Brachioplasty and back lift/ bra roll lift
- Thigh lift and breast lift
How to prepare for Body Lift surgery?
- A thorough understanding of the procedure and its limitations are important. Ensure you get all the information.
- Stop Smoking at least 2 weeks prior to the surgery day
- Get all the necessary tests recommended by your surgeon
- Eat healthy to ensure your protein and haemoglobin levels are good.
- It may be required to have iron injections or even blood transfusion before or after the surgery, a good haemoglobin level is key to good healing and recovery.
- Ensure you have all the pressure garments and medications necessary after the surgery.
What is the postoperative care after body lift surgery?
- You will require 5-7 days of good rest at home; some procedures may require you to stay for 2-4 weeks.
- It is recommended that you move around at home and do regular breathing exercises to prevent risks of deep vein thrombosis and chest infection.
- Stop smoking preferably forever, but at least 2-4 weeks during the recovery period.
- Keep taking your prescribed medications
- Keep in touch with your surgeon and ensure you attend all follow up schedules
- I personally prefer to keep the wounds dry and cover only with soft pads such as sanitary pads that absorb moisture and keep wound clean. I recommend not applying strong antiseptics/ alcohol or sealing the wounds, as it may be the cause of skin inflammation and infection.
- Eat healthy
What are the risks and how to avoid them?
- Any surgery may have risks of bleeding, hematoma, infection or wound breakdown. The surgeon would recommend you to stop all blood thinners such as aspirin, vitamin supplements etc. ensure you do not have any preexisting infection like boils, skin ulceration or cold and flu. During the surgery we take special precautions to avoid the above risks by giving Perioperative IV antibiotics, using tumescent fluid to prevent excessive bleeding and secure the wounds with multiple level of repair.
- Risk of Deep vein thrombosis can happen if the surgery is prolonged and if there are comorbid conditions such as varicose veins, obesity, chronic smoking etc. I strongly follow DVT prevention protocol that includes stockings stating previous night of surgery, sequential pneumatic compression during the surgery and postoperatively while in hospital, injectable Klexane that helps thin the blood without increasing risks of bleeding.
- Scar migration or stretching may happen due to inherent tissue weakness and collagen deficiency. We try and secure the wound along with anchoring to prevent this complication. Over-excision or overambitious tightening may also cause poor scar formation.
- Residual skin laxity and bulges with asymmetries may happen and is often due to primary asymmetry in body, poor skin quality and lack of perfect judgment due to position of patient during surgery.
- Changes in the result with time may happen due to continuing gravity effect, weight fluctuation, collagen breakdown. The tissues that appear very tight in the beginning always loosen up with time, the surgeon uses strong sutures to anchor the tissue but the body needs to eventually hold and heal in that position by producing enough and strong collagen.
- Breast surgery carries the highest risk of dissatisfaction and loss of result with time. The surgeon will do his/ her best to choose the correct size implant with adequate breast lift. But it’s a marriage of inconvenience between two opposing forces of breast skin tightening and implant volume that may have unpredictable long-term outcome. Hence a revision surgery may be necessary in 6-9 months period. [ref- Paolo Montemurro,Mubashir Cheema, Per Hedén, Benchmarking the Outcomes of Single-Stage Augmentation Mastopexy against Primary Breast Augmentation: A Single Surgeon’s Experience of 905 Consecutive Cases Plastic and Reconstructive Surgery • August 2019 ]
Classification of Contour Deformities after Bariatric Weight Loss: The PittsburghRating Scale Angela Y. Song, M.D., Raymond D. Jean, M.D., Dennis J. Hurwitz, M.D., Madelyn H. Fernstrom, Ph.D.,John A. Scott, M.S., and J. Peter Rubin, M.D. Pittsburgh, Pa.
I am Dr. Sanjay Parashar and have spent several years working with and learning from some of the best plastic surgeons in the world. I have been practicing for almost 3 decades and have performed over 12,000+ surgeries. My primary practice is based out of Dubai, UAE, but I travel to Delhi, mumbi and Ludhiana frequently to attend to VIP and celebrity cases in India. My specialties include:
- Breast Surgeries
- Breast Augmentation using Implants or/and Fat Grafting
- Breast Lift
- Body Lift
- Breast Reduction
- Facial Aesthetic Surgery
- Occuloplastic Surgery (Eye surgery)
- Reconstructive Surgery
- Robotic Hair Transplant
- Body Contouring –Liposuction and Liposculpting
- Six Pack Surgery using Vaser Technology
- Chest and Biceps Augmentation
- Abdominoplasty (Tummy tuck)
- Mommy Makeover
- Facial Contouring
- Fillers and Anti-ageing treatments
- Brazilian Butt Lift
- Gynecomastia (male breast reduction)