After losing 100 pounds or more, formerly morbidly obese patients are often healthier than before, but they also inherit a new troubling problem: excess skin hanging off every part of their face and body. Patients still don't feel good about their changed bodies. This loose skin can inhibit movement, chafe and result in rashes and infections. After years of stretching and contracting from weight gain and loss, their skin has lost its elasticity, just like a worn-out rubber band.

To correct these problems, patients often seek out plastic surgeons, who performed nearly 66,000 body contouring procedures in 2006, an increase of 18 percent since 2004, according to the American Society of Plastic Surgeons. This occurs after their weight has stabilized, which is usually about a year after their gastric bypass or banding operations. If facial surgery or body contouring procedures are done before their weight stabilizes, these patients risk being unhappy when more excess skin develops after further weight loss.

Final steps
Post-bariatric patients are highly motivated and frequently educated on body contouring procedures. They usually know that scars will be extensive and that their bodies can only approximate their pre-weight-gain appearance. They often come to the plastic surgeon referred by their general surgeon, support groups or the Internet. These procedures are the final steps in a quest to regain their former bodies.

In most cases, patients are paying for these complex procedures themselves. Third-party reimbursement is rare. Most insurance carriers, including Medicare, cover the expenses of bariatric surgeries but not of face and body contouring procedures, which are considered cosmetic.

During body contouring procedures, the surgeon removes excess skin and fat, which tightens the remaining skin. This can be done to nearly every part of the body. Each patient presents with different problems and concerns that determine the areas to be addressed. Initially, I focus on the parts of the body that most concern the patient. Most often, these are the abdomen and thighs. Arms, breasts and buttocks are other commonly treated areas.

The plastic surgeon determines, based on the health of the patient and the complexity and length of the procedures, whether the procedures will be done separately or combined. The surgeon must also decide whether the procedure will be performed in an outpatient or inpatient setting. When a patient is scheduled for one or two body contouring procedures and is in good health, I usually perform surgery in an outpatient facility. Whenever I anticipate more than several hours of surgery, I schedule the case as inpatient so the patient can be closely monitored. Body contouring procedures are almost always done under general anesthesia administered by an anesthesiologist. (See "Where Should Body Contouring Take Place?" below)

From arms to thighs
Here are a few common body contouring procedures:

• Abdominoplasty (tummy tuck). This is the most common procedure among post-bariatric patients. Because the weight gained by these patients is also intra-abdominal, weight loss results in a large separation of the rectus abdominis muscles. These are reapproximated with suture. Special care must be used to avoid damaging the port in the banding patient.

In a tummy tuck, a hip-to-hip incision is made and a very large amount of excess tissue is pulled down and removed. This also results in an "uplift" of the pubic area. Drains are usually inserted. After surgery, the patient wears a supportive abdominal binder for at least two weeks. The patient must also remain in a semi-flexed position for up to a week. Abdominoplasties are usually the most painful of body contouring operations because of the muscle repair. However, early ambulation is strongly recommended to help prevent complications such as pulmonary embolism.

• Brachioplasty (arm lift). The surgeon removes excess tissue, primarily skin, that hangs when the arm is extended. An arm lift may be combined with liposuction for further contouring. Variations and extensions of these incisions may also contour the upper back. I usually close these incisions with absorbable suture, staples and adhesive strips. Ace wraps provide support for the wounds. An arm lift is prone to form bad scars, which are raised, red and spread out. Fortunately, these scars usually become less noticeable with time. They can also be improved with revision surgery, lasers, compression and cortisone injections.
• Breast reduction. When a reduction in breast tissue is needed, excess fat, breast tissue and skin are removed. The more reduction required, the longer the scars, which may run along the surgically reduced areola, down the breast and out to either side. Because breast reduction has been shown to decrease neck and shoulder pain, it is frequently covered by insurance, depending on how much tissue is removed.
• Breast uplift (mastopexy). Male and female post-bariatric patients frequently present with little remaining breast tissue and loose, hanging, deformed breasts. A breast uplift, depending on its complexity, can be performed as an outpatient procedure and can be combined with placement of breast implants.

Implants will enlarge a deflated breast after weight loss but will not uplift it. Based on the uplift desired, I use one of several methods. In each procedure, I remove excess skin, but little breast tissue. In a minor uplift of about one inch, an ellipse of tissue is removed above the areola and closed. In a second method, the "donut uplift," I reduce the size of the areola and draw the excess skin to the areola. Unfortunately, the procedure doesn't uplift the breast very much, and can result in a flattened breast and stretched out areola with significant scars. A full mastopexy results in scars similar to a breast reduction. No breast tissue is removed, just skin, resulting in significant uplift and reshaping of the breast.

• Back lipectomy. Removal of excess skin from the back can be performed separately or by extending the incisions in a breast reduction. Liposuction — ultrasonic or power-assisted — is sometimes used to help contour these areas. Again, the resultant scars are quite long and may extend across the midline. In about 20 percent of cases, scars may be wide, red and raised above the skin surface.
• Body lift. A combination of a tummy tuck and buttock lift, this procedure can be performed in one surgery. Body lifts are becoming more common among post-bariatric patients. This operation yields significant improvement with less bunching of tissue compared to when each procedure is performed separately.

The cut is literally around the whole lower body. The surgeon removes the large masses of tissue, subcutaneous fat and skin. He then pulls down the excess abdominal skin, raises the pubic area and buttock, and then tightens the flanks. Part of the tissue can be used to augment the buttock area.

As with a tummy tuck, the rectus abdominis muscles are reapproximated. Drains are used and a supportive binder is placed. Afterwards, the patient is in slightly less flexion than after an abdominoplasty and movement is encouraged. I prescribe individually tailored precautions for deep vein thrombosis, such as alternating pressure stockings, TED supportive stockings and low-dose heparin. Body lifts are almost always done as inpatient procedures. I often have my patients donate a unit of their own blood, which is usually returned to them in the recovery room.

• Thigh lift. Thighplasty is a major procedure of several hours that sometimes includes liposuction. I usually perform thighplasty in an inpatient setting. The extent of the incisions vary, based on the amount and location of the excess skin. However, in most cases a cut descends from the pubis, around the thigh and up to the buttock. It often involves another incision down the inner thigh. Because of the location of these cuts, I don't perform thighplasty at the same time as a tummy tuck. Complications such as wound separation and even necrosis may occur because of the mobility of these areas and the tension placed on the wounds to achieve correction. After surgery, these patients must wear supportive garments for several weeks.

Mix and match
Massive weight loss changes the body so dramatically and in such different ways that I vary the surgical approach in order to safely achieve the improvement desired by the post-bariatric patient, who often wants to pass through the body-contouring phase as quickly as possible. Fortunately, patients who've lost more than 100 pounds understand that body contouring isn't a quick fix. They know that their body isn't going to change overnight. For them, though, body contouring may be the final step on a long journey to change their lives.