Loose skin after weight loss: which surgery to consider

Why is skin left behind after weight loss?

As obesity has become more common, more people are going through major weight loss, and demand for body contouring surgery afterward is also growing ^[1]. Skin that has been stretched for a long time often cannot shrink enough even when the fat is reduced, so sagging remains.

A 2015 review noted that after major weight loss, anatomical changes appear in each area of the body and that each area has surgical options to correct them ^[1]. Another review also explained that as the number of people who have lost a lot of weight has grown, the number and scope of body contouring procedures have expanded as well ^[3].

The role and limits of liposuction

Liposuction is mainly used to correct fat buildup in the deep and superficial fat layers and to refine body contours ^[4]. A 2017 review explained that liposuction has become a technique that complements the results of many procedures, such as abdominoplasty, arm lifts, thigh lifts, and body contouring after weight loss (bariatric) surgery ^[4].

This review judged that the complication rate of liposuction is very low compared with excisional surgery, and that major complications are usually related to inappropriate technique and inadequate care before and after surgery ^[4]. However, it should also be kept in mind that this is a narrative review based on experience in Western countries. Liposuction does not cut away skin, so when the skin is very loose, skin excision surgery becomes the main approach.

Surgical methods used for the abdomen

The abdomen is the most common area of concern for people who have lost a large amount of weight ^[2]. A 2019 review described the following procedures, and combinations of them, as ways of correcting the abdomen in this group ^[2]. The authors stated that the appropriate approach reflects both the shape the patient wants and the surgeon's assessment and experience ^[2].

• Panniculectomy, which removes the sagging skin and fat of the lower abdomen
• Standard abdominoplasty
• Fleur-de-lis abdominoplasty, which adds a vertical incision to the horizontal one
• Reverse abdominoplasty, which pulls the skin of the upper abdomen upward
• Circumferential abdominoplasty, performed all the way around the trunk, and the lower body lift

In what order are several areas treated?

The authors of the same review recommended limiting full-body reconstruction in weight loss patients to no more than 2 stages and including the abdomen in the first stage ^[2]. This is the authors' recommendation and does not mean the same order is right for everyone.

Along with the principles of patient selection and safety, a review of body contouring surgery also covered a key question: whether to stage several procedures or combine them ^[3]. The more that is done at once, the longer the surgery and the greater the burden of recovery, so the decision takes into account both your health and your circumstances in daily life.

What to look at before surgery

A 2015 review aimed to explain the nutritional and psychological problems that can arise in people who have lost a lot of weight, and it stressed that these problems are not a matter for surgery alone ^[1]. It stated that many issues need to be addressed before surgery begins and that surgery in this group involves considerations different from surgery in people who have not had bariatric surgery ^[1].

As bariatric surgery has become more common among men as well, more men are seeking skin excision surgery after major weight loss ^[5]. Because anatomy and surgical planning can differ between the sexes, there is also a review devoted specifically to abdominoplasty in men ^[5].

How are results assessed?

Questionnaires have also been developed to measure surgical results from the patient's point of view. The BODY-Q, a questionnaire for weight loss and body contouring surgery, was developed based on a literature review, interviews with 63 patients, 22 cognitive interviews, and input from 9 experts ^[6]. It covers 3 areas: concerns about appearance, health-related quality of life, and experience of care ^[6].

In other words, results are judged not only by appearance but also by daily life and the experience of care. The degree of loose skin and the recovery process differ from person to person, so it is best to discuss the scope and order that suit you through an examination.