Following weeks of recovery after major surgery, the last thing most people want to think about is doing it again.  If you are bariatric patient coming off of weight loss surgery, however, chances are this may be one of the first things on your mind.  After the extreme weight loss that follows bariatric surgery, 100 pounds or more in many instances, skin is left loose and saggy; excess tissue hangs from the abdomen below the belt line, and the hope of being able to finally feel comfortable in "normal" clothes is postponed by hanging flesh that just doesn't seem to fit on your much slimmer frame.  Many patients like this turn to plastic surgery to help contour the body, giving shape to their new form.

An Emotional Decision

According to Manhattan plastic surgeon Dr. Steven Wallach, many post-bariatric patients are a little discouraged; they have lost around 100 pounds or more and aren't looking as good as they feel.  And this isn't the only problem afflicting this type of patient.  Not only have they just gone through an extensive recovery process and are trying to adapt to a whole new way of living, many are fighting a battle against food addiction.  Dawn Falkiner, R.N. with Dr. Peter E. Johnson's Center for Aesthetic Surgery in Des Plaines, IL says that many of the patients that she sees have more problems than just a flabby abdomen and are often under psychological counsel as well.  "We have to spend a lot more time with these patients," she says of the pre-operative consultation.  She says that the doctor will often do an initial consultation, allow the patient to review videos, and then offer another chance for any follow up questions. 

Another reason for the extended time and attention that this type of patient needs is that each case is different, and the surgeon needs to make sure that all desires are addressed.  Dr. Dennis Hurwitz, Clinical professor of Surgery (Plastic) for the University of Pittsburgh Medical Center, says that he takes a "comprehensive approach," discussing all body parts from the face and neck down to the legs, making sure the patient knows all of the possibilities.  If you are a patient that has just achieved significant weight loss, you know that hanging skin doesn't just accumulate in one area; the whole body has sagging skin and tissue left over from your bigger self.  If just a portion of this hanging tissue is remedied - if only the abdomen skin is operated on for example - it can create an asymmetrical appearance of the body.  So when preparing for surgery you should be aware that altering one area can produce a different look to the whole body.

Staging Surgery

For most patients who are wishing to undergo a major body overhaul, surgery is usually done in stages.  The surgeon will begin with the areas that are posing the most immediate concern: usually the abdomen and buttocks and breasts for women.  Surgery is performed by cutting away excess skin and tissue, and bringing the remaining skin tight against the body.  Because the aesthetic problems effecting post-bariatric patients is loose skin and not pockets of fat, liposuction is used with less frequency, if ever, even though, according to nurse Falkiner, many misinformed patients come to their initial consultation expecting this procedure.

5'5" 200 pound female with 160 pound weight loss
Abdominoplasty, incisional hernia repair, lower body lift and bilateral brachioplasties
The second stage was vertical thighplasties, upper body lift and breast reductions
Surgery performed by Dr. Dennis Hurwitz
Photo taken 18 months post-op

The actual surgical approach depends mostly upon your surgeon and your personal desires.  At Dr. Johnson's surgical center, many patients are operated on in the morning and return home that very night, while Dr. Hurwitz's patients tend to spend more time in surgery and 3-4 days recovering in a hospital bed.  Neither approach seems to make a difference in the rate of occurance of complications, one style offering a quicker return home and the other offering the chance to have more areas addressed at once with a longer surgical time.  Ultimately the patient's comfort level with the operating surgeon is what's most important.

Heavy Consideration

While most surgeries of this sort are successful, and patients come out feeling much happier with their appearance, there are certainly many factors to consider before lying down on the operating table.  Aside from psychological issues that might prevent some from being good candidates for surgery, there is also the small possibility of protein deficiencies and malnutrition as a result of bariatric surgery that will keep hopeful patients out of surgery.  Because of this possibility many doctors, like Dr. Hurwitz, have nutritionists on staff to assess each individuals needs.  Of course if weight loss is not yet complete, then surgery is called of as well.  Most patients' goal is to loose 100 pounds or more after bariatric surgery, if their goal is not met or the patient is still obese, surgery may not be a viable solution.  Typically, surgeons will wait about a year or slightly more following weight loss surgery before performing cosmetic surgery on a patient. 

Along with bariatric surgery comes the increased risk of a hernia.  Dr. Wallach says that about half of his post-bariatric patients come in with a hernia, most pre-diagnosed, and opt to have this problem remedied at the same time.

Reaching Your Aesthetic Goals

Aside from health concerns there are also specific aesthetic concerns: after all the surgery is performed to improve appearance; patients should make the most of it.  "Scars are the name of the game," says Naples, Fl surgeon Dr. Manuel M. Peña.  "Where they will be and what they will look like for how long should be the main questions."  Scars are inevitable.  However, many surgeons are able to hide them along the bikini line, under the armpit, or underneath the breasts in women in order to minimize visibility. 

5'8" 180 pound female with 160 pound weight loss
Lower body lift, medial thighplasty, bilateral brachioplasty
And upper body lift with spiral flap augmentation
8 months later she received 300cc. breast implants and vertical thighplasty
Surgery performed by Dr. Dennis Hurwitz
Photo taken 1 year post-op

There is also the process of wounds healing.  Because patients can have as much as 20 to 30 pounds of skin and tissue removed during surgery and incisions are sometimes deeper than in a traditional patient, more pressure can be put on sutures holding skin together.  Couple this with other health and skin problems that patients might have and you get a higher opportunity for wound problems and suture separation.  Careful attention to this post-operatively is important to ensure minimal scarring.

Risks of Surgery

All surgeries carry risks, but because of the magnitude of this type of major body surgery, there are unique risks that present themselves.  One of the most prevalent is the appearance of seroma, or excess fluid trapped in the body.  As Nurse Falkiner explains it, because the body has suddenly lost around 20 pounds of flesh that use to allow fluid to move through it, the fluid will build up in certain areas since it now has nowhere to go.  The remedy of this problem can be accomplished by simple draining, however, sometimes tubes will have to remain for drainage for as long as a week or more.  Another possible problem that can be cured by drainage is hematoma, or internal bleeding.  While both hematoma and seroma can be serious enough to warrant additional surgery or admittance to the hospital, this is rarely the case.  Infection is also a possibility, however Nurse Falkiner said that their practice has found a way to negate this possibility.  Since they have been performing these surgeries in their office, and not in a hospital setting, they have had no patients that suffered from infection.

The most important thing that patients should be aware of is that this will not be the same type of recovery process as the one after the bariatric procedure.  On the whole patients experience less pain and may feel rushed to get back to the exercise that has allowed the weight loss success that they have had.  Just because you feel less restricted doesn't mean that your body can handle strenuous activity, beside the fact that you could rupture sutures.  Your doctor will require frequent follow up visits for the first several weeks, and periodic visits thereafter to assess your progress.  By following the instructions at each visit you will be able to stave off possible complications due to overexertion.

An Affectual Change

For many, plastic surgery after major weight loss can be the last step to regaining health and a better self-image.  Dr. Wallach says that many of his patients have already reversed some of their medical problems by the time they come to his office and become less dependant upon antidepressants as they go through surgery with him.  "It's like a veil that's been lifted from them," he says of their attitude and affect afterwards.  Dr. Peña agrees: "Although post weight loss cosmetic surgery is not a cure all, it rewards these individuals with a way to get their 'insides' to match their 'outsides'.  These are some of the happiest patients I've ever worked with."