Submitted by Daniel A. Sterling, MD, FACS

 Can a thigh lift and arm lift be performed at the same time? Cost is a factor for me as is time. I have lost a great deal of weight and these are the areas that are most concerning.
 

Certain body contouring after massive weight loss procedures can be combined. An example would be combining a thigh lift and an arm lift in the same operative setting. The usual determination for combining procedures is the length of operative time and this combination falls within approximately five to six hours in total operative time. Combining the cases would limit the costs of the operating room and anesthesia to a degree.

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Submitted by Dr. Daniel A. Sterling

I have lost volume in my face due to weight loss. I am most concerned with my eyes, they are very hollow and sunken looking. Is there a procedure or facial filler that you use to replace the lost volume?

Multiple areas of the body are effected following significant weight loss.  Different areas of the face including the eyes can be effected significantly as well.  Although fillers can be used in specific cases to augment various areas of hollowness in the face the eyes are somewhat less responsive.  Excess loose skin can contribute to a hollow sunken look and by removing that excess skin a greatly improved contour can be achieved.

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Submitted by Dr. Daniel A. Sterling

I  am going through a stressful situation and have lost a great deal of weight (50 lbs). I am 5’ 6” and weigh 115 lbs. I have been trying to gain weight but have not been successful no matter how much I eat. I have a lot of excess skin in my abdominal area and would like to have it removed. Am I a candidate for this procedure?
 

When someone loses a significant amount of their body weight unintentionally it is important to make sure that your overall health is good. Once you ensure that there are no underlying health problems your physical appearance can be addressed. Elective cosmetic procedures are only done under the safest circumstances. If there is a lot of excess skin following your weight loss you are in all likelihood an excellent candidate for an abdominoplasty (tummy tuck) because people who see the best results are those who have minimal excess body fat and mostly excess abdominal skin.
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Submitted by Dr. Daniel A. Sterling

I have been trying to loose weight for the past six months. I am 6’ 2” and currently weight 280 lbs. I am very discouraged as the weight is coming of slowly (I have only lost 20 lbs). I am considering liposuction of the abdomen as I feel it will give me more energy and I will be able to exercise longer without the added weight. Should I consider liposuction?
 

Liposuction is not considered a massive weight reduction surgery. However, it can in the right circumstances improve ones ability to exercise. Certainly large volume liposuction, which is considered liposuction of any volume over five liters, can significantly decrease the abdominal girth which allows one to fit and feel better in their clothing which in turn may encourage one to participate in exercise activities more often. Usually the removal of large amounts of fat by liposuction can result in some loose skin but that can be addressed when the person is at or near a relatively ideal weight.
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Submitted by Dr. Daniel A. Sterling

I have arthritis in my shoulders. I feel the excess skin hanging from my arms adds to my discomfort. Will having the excess skin/weight removed help?

Certainly removing any heavy skin or fat from the torso can alleviate certain types of joint and back pain. Skin itself is not significantly heavy and if that is the only problem that is present in the arms it is unlikely that simple removal of the excess skin will improve shoulder arthritis. If in fact there is a significant amount of excess fat it may improve your symptoms in combination with other standard arthritis therapy.

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Submitted by Dr. Daniel A. Sterling

I have been researching surgery after weight loss and feel one of the procedures I am a candidate for is a panniculectomy. I am confused about the difference between this procedure and an abdominoplasty.

The difference between a panniculectomy and abdominoplasty is one of functionality versus cosmetic. In other words, a panniculectomy is a removal of a large fatty overhanging apron which may have skin infections etc. for a functional purpose so that the person may ambulate or exercise better. An abdominoplasty on the other hand is aimed at improving the cosmetic appearance of a less severe overweight or sagging abdomen. In either case there is a vast improvement in one’s appearance, however, one is considered a functional operation and the other one cosmetic. The operation itself is very similar except for a few small technical details.

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Submitted by Dr. Daniel A. Sterling

I have lost 70 lbs through diet and exercise. I am thrilled with the results except for the fact that I no longer have breasts. I am considering breast augmentation. After visiting your website it appears I may need a breast lift, however, want minimal scarring. Is this possible?
 

Following massive weight loss there are usually significant changes to the appearance of a woman’s breasts. The vast majority of women have loss of volume (deflation) due to the loss of fat within the breast. In most cases some type of breast lift (mastopexy) will be required to bring the nipple up to the correct position and decrease the size of the skin envelope. This will improve the contour of the breast. A breast implant may or may not be required and that can usually be determined at the time of your consultation. Regarding scars, there is a broad spectrum of the type of mastopexy that can be used but in most massive weight loss patients, the type of mastopexy required will require some scarring. Most women however are very happy with the appearance of the scars because they heal well, the breasts have a better shape and the lower part of the scar is hidden in the breast fold.

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Submitted by Dr. Daniel A. Sterling

I had  gastric bypass surgery in January of 2007.  I lost 110 pounds and still have 20 pounds to lose to reach my target weight.  I seem to have reached a plateau as I am having a difficult time losing the last 20 pounds.  Do I need to lose this weight before I start the process and consider weight loss surgery?

It is not uncommon for patients to plateau en route to reaching their “ideal weight.”  No one is exactly sure what an ideal weight is, thus that should be determined by your surgeon and nutritionist.  Optimally you will have reached your target weight but certainly 20 pounds will not make a significant difference in your final result. In either case, if you have your surgery and are able to exercise more efficiently and lose the additional 20 pounds small touchups can be done to remove any residual excess skin that may still be present.  

Submitted by Dr. Daniel A. Sterling

I have lost 60 pounds through diet and exercise, I now have saggy breasts.  Will breast implants help?

A loss of 60 pounds is considered massive weight loss.  It is very natural to have sagging breasts after weight loss as a significant portion of the breast is fat.  The older a woman is the more fat she has in her breasts, and thus weight loss will affect the size and shape of her breasts.  Depending upon the amount of ptosis (breast sag) a number of different approaches may be used.  Women with minimal ptosis may be candidates for augmentation mammoplasty alone.  If the degree of ptosis is more severe an augmentation is usually combined with some type of mastopexy, anything from a crescent mastopexy to a full Wise pattern (anchor) mastopexy.  A good way to judge for yourself is to gage the level of your nipple. If your nipple is at or above the level of your breast fold then usually implants alone will be sufficient.  If the nipple is significantly lower than the fold then a mastopexy is usually required in combination with the augmentation.  All of this can be determined at your initial consultation. 

Submitted by Dr. Daniel A. Sterling

I had gastric bypass surgery two years ago and lost 140 pounds.  I exercise three to four times a week.  I am 5 foot, 4 inches and my weight is 140 pounds.  Some areas of my body have responded well in that the skin has tightened.  My abdomen, however, has a lot of excess skin, as well as the upper portions of my arms.  I read your website and feel that I am candidate for a tummy tuck and arm reduction, can these procedures be performed at the same time?

It certainly sounds like you have lost the majority of your excess body weight and have maintained that weight loss for a significant period of time.  The redundant skin that is present will not respond to exercise and therefore surgical correction is the only option to give you the result that you desire and deserve.  Certain procedures can be combined, usually based on the length of the procedure.  Depending upon the severity of the deformity, certainly a brachioplasty (arm lift) and abdominoplasty (tummy tuck) could be combined. Many people need a circumferential lower body lift rather than an abdominoplasty as this gives the added benefit of a buttock lift and a lateral thigh lift at the same time.  A brachioplasty is normally about a 2 hour procedure.  It is my experience that patients do much better recovery wise when surgery is limited to approximately 5 hours under general anesthesia. Procedures longer than 5 hours make recovery for the patient far more difficult and increase the incidence of complications.  That being said, an abdominoplasty and brachioplasty combined should take approximately 5 hours. 

Submitted by Daniel A. Sterling, MD

Bariatric surgery is being performed on older patients every year.  The techniques have become much safer, as has the perioperative management of massive weight loss patients.  Certainly you will benefit greatly from your Lap Band surgery and any comorbidity such as hypertension, diabetes, sleep apnea will likely be significantly improved or cured following your weight loss. 

Body contouring after massive weight loss is not contraindicated in older patients, as long as there are no other significant conditions that may jeopardize your safety.  Remember, the safety of the patient is the primary concern in all of these elective procedures. 

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Submitted By Dr. Daniel A. Sterling

Many areas are affected during massive weight loss. The face is certainly no exception.  Some patients have all areas affected while others have specific areas affected. The most common areas which are affected are the face and neck, the arms, the breasts, the abdomen, buttocks and thighs.  When a significant amount of fat is lost the face loses volume and the skin tends to sag.  In very mild cases, this may be corrected or improved with use of facial fillers.  Other patients require a lower face and neck lift.  Both can give excellent results.

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Submitted by Dr. Daniel A. Sterling

I am a post-gastric bypass patient in need of multiple procedures.  I know all of the procedures I will need cannot be performed at the same time.  How long do I need to wait in between procedures?

Depending upon which procedures are indicated, there is a possibility that certain procedures can be combined.  My personal preference is to perform the circumferential lower body lift as the initial procedure, as that will give you the biggest change in lifestyle and allow you to be more mobile and exercise more efficiently.  If breast and arm procedures are indicated they can be combined. It is even possible to combine a thigh lift with a brachioplasty (arm lift).  My experience has taught me that the “extreme makeover approach” that is so frequently seen on TV is not in a patient’s best interest.  Recovery is much more difficult and complication rates are much higher when a patient has 10 hours of general anesthesia.  In terms of the time period between procedures, certainly three to six months would be prudent between major surgical procedures.  Remember, your safety is the number one priority while you are on the journey to your new body and lifestyle. 

Submitted by Dr. Daniel A. Sterling

What is the difference between a tummy tuck and a mini tummy tuck, and how do I know which procedure I am a candidate for.

A mini tummy tuck is very rarely indicated and is limited to people who have a small amount of redundant skin below the belly button.  The vast majority of people have excess skin both above and below the belly button, as well as loosening of the underlying abdominal wall.  For certain people with a very limited amount of redundant skin and a small amount of excess fat a mini tummy tuck may provide the result they are looking for.  However, the majority of people get a much more comprehensive result with a full tummy tuck and the resultant scar is not significantly larger than that of a mini tummy tuck in any case. 

Submitted by Dr. Daniel A. Sterling

My husband has lost 60 pounds in the last year.  He did this by eating healthy and walking daily.  He looks and feels great, however has excess skin in his chest area.  Is there a procedure to remove the excess skin?

There are multiple areas affected during massive weight loss.  Both men and women demonstrate significant changes of the breasts following massive weight loss with the usual result being excessive sag and redundant skin.  In addition, there may be a large amount of stretch marks.  Depending upon the amount of excess skin and residual fat, any one of a number of procedures may be indicated to correct the deformity. For certain people, liposuction alone can correct the residual fatty excess, while other people require resection of the redundant skin.  Regardless of the procedure, results are often excellent with great patient satisfaction. 

The breast lifting operation (also known as mastopexy) is a commonly performed procedure for women who have breast sag (mammary ptosis). Many types of breast lift are possible from the simplest crescent mastopexy in which a 1-2cm skin only crescent removal is done for less severe breast sag, to more complex procedures such as vertical or anchor mastopexy for more relaxation of the breasts.

Woman who have major or massive weight loss (more than 100lbs) often experience severe deflation of the breasts, resulting in the so called “empty sacs” in which the breasts consist of mostly skin, and very little underlying fat or gland. In these patients there is usually considerable downward movement of the nipples. Correction of this problem often requires a full breast lift such as an anchor mastopexy together with the insertion of breast implants to recreate the fullness of the breast. Implants can be inserted at the same time or at a later date, depending in the deformity.

Left Photo (Pre-op): 37-year-old female, 5'0", 150 lbs.
Pre-op bra size: 36C
Massive weight loss resulting in breast hang (mammary ptosis). Classic breast appearance of the massive weight loss patient.

Right Photo (Post-op): 2 months after full breast lift.

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It is well known that obesity has become a major problem in the United States. We routinely see patients who have lost well over 100 pounds. Numerous medical problems are present for patients who are so overweight, and it is amazing how quickly diabetes gets under control with massive weight reduction.

What many patients do not know is how excellent the scars are after surgical body contouring.

The most common area operated on after massive weight loss is the abdomen extending into the back. A circumferential scar extends from the lower abdomen around the lower back, in this way removing the large abdominal pannus as well as tightening the back and lifting the buttocks. The scar falls into the natural creases and therefore heals very well. It is easily hidden in bathing suits and underwear.

Before and After Photographs

This 55-year-old female had a laparoscopic gastric bypass 18 months before her circumferential lower body lift. Her pre-op weight before the gastric bypass was 230 lbs. with a BMI of 39.5. Her post-op weight after the gastric bypass was 155 with a BMI of 26.6. The circumferential lower body lift photographs are at 5 weeks. The scars will continue to fade during the next 6 to 12 months and become white and less noticeable.

Other areas that often require surgery are the arms, breasts and face. Here too, surgical scars are created in favorable locations, making for excellent healing.

Patients are very grateful after surgical correction for massive weight loss. They have made the major effort of weight loss and are rewarded by having a body they can be proud of with scars that usually blend into their normal contours.

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Surgery News, Volume 3, page 1, February 2007 published a lead article describing the medical benefit of bariatric (weight loss) surery. In addition to weight loss, it also produces rapid improvement of glucose tolerance, blood pressure, lipid levels, diabetes, and the risk of coronary heart disease.

The average 10-year risk of coronary heart disease dropped to 2.7% versus 5.4% in a study of 500 patients. It was felt that the decrease was due to improvements in blood pressure and low density (LDL) and high density lipoproteins (HDL) as well as Type 2 diabetes.

This article is of importance in that it supports other research showing the health benefits of gastric bypass surgery.

We feel that there is a great deal we can offer the massive weight loss patient. Many areas of the body develop sag following massive weight loss. Reconstructive and cosmetic procedures help rehabilitate this type of patient from breast tightening procedures to arm lifts to abdominoplasty and body lifting procedures.

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