When author Frances Kuffel reached her goal weight -- after losing more than 200 pounds -- she didn't even realize how far she'd come.
"I kept thinking 'I'm still fat; I still look awful.' Someone else had to point out that my problem was no longer fat -- it was skin, all this excess skin from losing so much weight," says Kuffel, author of Passing for Thin.
As weight loss surgery becomes more popular, weight losses of 100 pounds or more are becoming common. But, experts say, the result can be at once rewarding and cruel, as layers of excess skin replace lost layers of fat.
"People who lose 100 pounds or more feel healthier, they know they are healthier, they can do things they could not do before. But when they look at their body, it's a constant reminder of where they were – and it can sometimes make it difficult to move on with their life," says J. Peter Rubin, MD, director of the Life After Weight Loss Surgery Center at the University of Pittsburgh School of Medicine.
A relatively new medical subspecialty, body-contouring plastic surgery was developed to address the aesthetic concerns of those who have lost large amounts of weight -- whether through dieting alone or with the help of weight loss (bariatric) surgery.
"Very often, it's that final step in achieving the body that many people envisioned they would have when they signed on for weight loss surgery," says Stephen Colon, MD, chief of plastic surgery at Hackensack University Medical Center in New Jersey.
According to the American Society of Plastic Surgeons, in 2005 more than 68,000 people opted for body-contouring surgery following weight loss – an increase of 22% over 2004.
Types of Body-Contouring Surgery
While operations like the tummy tuck and breast lift have been around for decades, what makes body-contouring surgery different is both the amount of skin that is removed and the fact that procedures usually cover more than one area of the body.
"The most popular [procedure] in our center is the lower body lift, which includes the tummy, outer thighs, and the area around the midsection," says Rubin.
Other choices include an upper body lift, which focuses on the breasts and back, as well as lifts for the arms, inner thighs, and the face and neck.
Because some of these operations can be lengthy, one of the newest approaches is to use two or more surgeons working simultaneously on a single patient, Colon says. This helps reduce the amount of time spent under anesthesia, and that, in turn, may speed recovery, he says.
But even with a surgical team, Rubin says, a multiprocedure involving the abdomen, a lower body lift, breast lift and arms -- a common combination -- could last eight or more hours.
How Safe Is It?
Among problems that have been cited are wound infection, reopening of wounds needing surgical drainage, and excess bleeding requiring a second surgery, Rubin says. Blood transfusions are also needed about 15% of the time. In rare instances, patients have developed fatal blood clots.
While some of these problems still occur (notably the need for transfusions), experts say it's on a much smaller scale in the last few years. In a study presented in 2003 at an American Society of Plastic Surgeons conference in San Diego, researchers found that many such complications could be avoided if patients allowed more time to elapse between weight loss surgery and plastic surgery.
The research reported that patients who underwent bariatric surgery (weight loss surgery on the stomach and/or intestines) who waited about a year before undergoing body-contouring surgery saw a reduction in the complication rate -- and ended up with shorter hospital stays. The researchers also reported that waiting allowed the death rate to drop dramatically, from 14% for those who had body-contouring surgery soon after losing the weight, to 0% for those who waited.
Today, Colon says, most patients are advised to wait at least one year after bariatric surgery.
But even when patients do wait, problems can still occur -- including a dramatic loosening of the newly tightened skin that sometimes requires a second round of surgery, Rubin says.
"We can't predict who will be affected and we don't know why it happens, but it does. Some people actually need more surgery," says Rubin.
Body Contouring: Is It For You?
Not everyone who loses a lot of weight needs body-contouring surgery. Moreover, experts say, not everyone needs it for the entire body.
"A lot depends on your age, your genetics, level of sun exposure, how evenly the weight was distributed, and, more importantly, how you feel when you look in the mirror," says Colon. "If you're not unhappy about the way you look, you shouldn't be made to feel you need body- contouring surgery."
Those least likely to want or need the procedure, he says, are usually under age 40. "The majority of the patients I see for this surgery are over 40. It's pretty hard to avoid the slackening effect of the skin after that age," says Colon.
What can also make a difference, however, is where you lose the weight. While a loss of 50 pounds that was concentrated in your midsection might leave you with a lot of loose skin in that area, a 100-pound loss that was more evenly distributed on your body may have less of an effect on skin.
If you do end up with droopy, sagging skin and think there's some other way around it, experts say, forget it.
"Short of surgery, there is really nothing that can help. Exercise won't tighten it, and skin creams and lotions won't do a thing to help," says Nolan Karp, MD, associate professor of plastic surgery at New York University Medical Center.
But body contouring doesn't come cheap. The average price of a full-body lift is around $30,000. Arm surgery runs in the range of $8,000, while inner thighs cost about $10,000 a pair. A breast lift and upper back surgery will set you back about $15,000, and a neck and face lift would add another $15,000 to the bill. (As you probably already guessed, insurance rarely covers any of it.)
When you add to this the need for four to six weeks of at-home recovery, for many, spandex can seem like the only viable option.
In an attempt to make things easier, many doctors use finance companies to help patients work out a kind of "plastic surgery mortgage" -- a payment plan that allows you to reduce the size of your midsection without paying an arm and a leg up front.
Doctors say they also help patients rationalize the expenditure, frequently comparing it to the purchase of a new car.
"Many people wouldn't hesitate to spend $30,000 for a new car. So I ask them, after all that hard work losing the weight, aren't you worth the same $30,000 to look the way you want to look?" says Karp.
7 Things to Do Before Having Surgery
If you are considering body-contouring surgery, here's what experts we talked to said you should do first:
- Stabilize your weight -- at your goal -- for at least three months, and be sure to correct all nutritional deficiencies (which are common after weight loss surgery).
- Establish a reliable support network of family and friends to help you during recovery.
- Make sure you can get enough time off from work to recover. It will take 4-6 weeks depending on the procedure.
- Understand that everything is a trade-off between removing skin, getting a contour, and having a scar. Scars are permanent. They do get lighter, but don't disappear over time.
- Prioritize your body according to the area that bothers you the most, and concentrate your surgery there first. You may find you don't need additional procedures.
- Prior to surgery, stop smoking (to reduce complications) and increase your protein intake to 50 to 70 grams per day to speed healing.
- Choose a surgeon who is board-certified in plastic and reconstructive surgery -- not just a board-certified doctor.