Skin Repair
From Northern Virgina Magazine, October 2009
by Kristen Cooper
For years many struggle with nagging weight issues. Options to dissolve pounds include diets, exercise and in more serious cases, bariatric surgery. Even after successfully shedding extra weight, skin may not return to its original state. According to Dr. Michael F. Chiaramonte, medical director of Bella Cosmetic Surgery, "Due to inadequate skin elasticity, massive weight loss often results in surpluses of skin." Exercise alone is unsuccessful at ridding this, so cosmetic surgery is an option for repair.
There are many cosmetic procedures that surgeons use to help individuals who have lost a considerable amount of weight. Depending on the amount of excess skin and fat, individuals should research and choose the procedure that is right for them and their lifestyle. Breast lifts, arm lifts, abdominoplasty (tummy tucks), thigh lifts and lower body lifts are a few of the popular options that can help re-sculpt and revitalize post-weight loss bodies.
Maxopexy (Breast Lift)
Duration of surgery: 2 hours
Return to regular activity: 1 week
Resume exercise: 4 weeks
Unfortunately, gravity does not favor women's most feminine assets. Weight loss or fluctuation, pregnancy and breastfeeding can also contribute to the decision to turn to cosmetic surgery for a breast lift. Patients have the option of adding implants, as well, to further reach their desired results.
According to Dr. Mitchel Krieger, Fairfax-based cosmetic surgeon, the majority of women opting to have the procedure have had children in conjunction with fluctuating weight. The breast lift is performed by removing the excess skin that causes sagging and repositioning the breast tissue higher on the chest. Depending on the patient, doctors can also re-sculpt and reshape the breasts to return the patient to a more youthful appearance. Based on the degree of droopiness, Krieger says, complexity of the procedure varies. For minimal drooping, a circular incision around the nipple is sufficient; others require a "lollipop incision" (around nipple and vertically down to the fold under the breast) or "anchor incision" (an additional incision along the fold). Excess skin is removed, followed by a "[lifting] of the breast tissue and nipple/areola complex to a more youthful position on the breast".
As with any other surgical procedure, bleeding, pain and infection are possible complications of a breast lift. To prevent the occurrence of either, patients are tested prior to surgery for any bleeding disorders. At the Bitar Cosmetic Surgery Institute in Fairfax, patients are given antibiotics during the surgery and are "prescribed a one-week course of antibiotics to minimize infection," Dr. George Bitar says. Another complication that many patients fear, but few encounter, is the inability to breastfeed after a breast lift. According to Dr. Christopher Hess of Hess Plastic Surgery, "a breast lift does not generally interfere with breastfeeding," but "pregnancy's effect of increased breast size can work against the benefits of a breast lift." The addition of an augmentation to the procedure also adds risks of deflation or hardening of the implants.
Midsection (Abdominoplasty and Lipoabdominoplasty)
Duration of surgery: 2-3 hours
Return to regular activity: 1 week
Resume exercise: 4 weeks
According to Chiaramonte, "the first procedure people ask for is one to address their abdomen." Commonly known as the tummy tuck, abdominoplasty functions to remove droopy excess skin and fat in the midsection. A low incision is made from hip to hip, followed by the surgeon separating skin and fat from the muscle underneath all the way up to the ribcage. "We put in sutures to tighten the tissue surrounding the muscles so the abdomen doesn't have any weakness anymore and then the extra skin and fat is cut out," Krieger says. "Then, we flex the patient so we can close the wound and sew things back together."
Although tummy tucks are very popular and can yield substantial results, some patients want to improve other areas of the midsection besides the lower abdomen. For this type of client, Chiaramonte developed the Bella Body Lift, a complete upper body contouring procedure that removes excess skin and fat from below the breast area, middle and lower abdomen. Also known as lipoabdominoplasty, this procedure combines abdominoplasty with liposuction to yield positive results. One patient, Lyndsey, underwent the procedure in December 2008 after struggling with excess weight after pregnancy. "I gained about 70 pounds during my pregnancy and had a lot of loose skin that I couldn't get rid of. I tried for about eight years and then decided to do the procedure," she says. When asked how she felt about the results, Lyndsey says, "It did more than I thought it would, and I'm very happy." Krieger advises those considering the surgery to exercise caution: "You do run a greater risk for wound healing problems with lipoabdominoplasty [because] you're interfering with a lot of the natural blood supply to the tissues," Krieger says. "If someone needs liposuction in addition to the general abdominoplasty, I'll do it as a secondary procedure later on."
Candidates who qualify for abdominoplasty or lipoabdominoplasty are generally those who have lost a considerable amount of weight or have gone through multiple pregnancies. "Typical patients have had significant weight loss and their weight has stabilized," says Chiaramonte.
As with any surgery, the complication of bleeding can occur. To prevent this, surgeons test patients for any bleeding disorders before surgery. In addition, tumescent solution, which combines high volumes of saline, a numbing agent called dilute lidocaine and adrenaline is used during the tummy tuck before liposuction to minimize the chance of bleeding. "Specific to this procedure are contour-related problems: not taking enough or taking too much skin," Krieger says. Patients are advised not to smoke as those who do see complications more often.
Arm Lift
Duration of surgery: 1-2 hours
Return to regular activity: 1 week
Resume exercise: 4 weeks
No matter how many hours are spent on doing push-ups and pull-ups, many individuals still suffer from loose and flabby skin on their upper arms. Although exercise can tighten the arm muscles, the skin may still look loose and droopy. Unhappiness due to saggy arm skin can inhibit confidence in terms of clothing and fashion choices, but an arm lift can remove the skin that weight loss leaves behind. During the arm lift procedure, surgeons make a Y-shaped incision from the arm pit to the elbow to remove excess skin and fat to create smoother and firmer upper arms.
Desirable candidates for this procedure are those who have rapidly lost a lot of weight, and are not going to lose any more. This can include individuals who have lost weight due to bariatric surgery or from diet and exercise. "Once gastric bypass patients' weight has stabilized then they are appropriate candidates," says Chiaramonte.
Possible complications that can occur during an arm lift are bleeding and nerve injury. Nerves can occasionally bruise during an arm lift and can result in loss of feeling or numbness, but regain all functionality within a few days.
Thigh Lift
Duration of surgery: 2-3 hours
Return to regular activity: 2 weeks
Resume exercise: 4 weeks
Another problem area that can be undesirable and physically uncomfortable is sagging skin on the inner thighs. Rapid weight loss and aging both contribute to this problem. Although exercise will help tighten the thigh muscles, the skin may still appear loose and saggy due to the loss of its elasticity. Thigh lifts can help reduce this appearance, and can also be combined with liposuction on the outer thighs if the patient desires.
"This is not an operation a lot of people are candidates for," says Dr. George Weston of Reston-based Virginia Plastic Surgery. "Typically it is for people who have had major weight loss."
Weston also warns that "this operation is not designed to do what patients want it to do," explaining that the procedure only focuses halfway down the thigh, not all the way to the knee.
A crescent-shaped segment of skin and fat are taken off the inner thigh to reduce the problem of thighs rubbing together. Weston says, "[the patient] gains better contour but there is a scar, from the knee to the groin, typically in the crease of the thigh." Most patients have reasonable results, he adds.
In terms of recovery, Weston notes that there will be swelling for a few days, sutures usually come out within a week. There is moderate pain and, as with any surgery, a risk of infection.
Chiaramonte notes that weight stabilization is very important before seeking this procedure. "It's all about stability of their weight, meaning, ‘This is who I am now,'" says Chiaramonte. He stresses the importance of weight stability before surgery, and patients should not plan on any more significant gain or loss after surgery.
Although complications are generally rare, patients should be aware of the possibilities before they undergo surgery. Some possible complications after having a thigh lift include: bleeding, infections and nerve injury. At the Bitar Cosmetic Surgery Institute, doctors place a drain under the skin after the operation to control the instance of bleeding. Other complications that can occur include infections or wounds. When tension from typical movement is placed on the inner thighs after surgery, the uncomfortable result can be wounds on the thighs. In order to treat this, doctors prescribe antibiotics and apply dressing to the affected areas. Nerve injury occurs when the nerves get "stunned or bruised" during surgery, and "function may take a few days to weeks to return."
Lower body lift
Duration of surgery: 6 hours
Return to regular activity: 4 weeks
Resume exercise: 6 weeks
The lower body lift procedure, also known as a circumferential abdominoplasty, is a combination procedure that addresses problems in the stomach, waist, hips, outer thighs and buttocks. The complexity and length of this procedure drastically improves the saggy appearance of skin for patients who have lost a considerable amount of weight.
Desired and appropriate patients for a lower body lift procedure are those who have already had bariatric surgery. "Patients tend to be in their 30s or 40s and have typically gone through a lifestyle change," says Chiaramonte. Patients seeking this procedure are those desiring a complete lower body makeover, which leads to the complex nature of the surgery. According to Chiaramonte, "Patients who have gone through gastric bypass have profound skin issues and are more likely to be patients requiring a circumferential abdominoplasty."
Since bleeding is a common occurrence with this procedure, in order to ensure the patient doesn't lose too much blood they are asked to "have either themselves or relatives donate a total of two pints of blood that will be given back to them during the operation," says Bitar. In addition, complications can include infection, nerve injury and seromas, fluid collection under the skin. Antibiotics are prescribed to patients for two weeks after surgery to prevent the possibility of infection and wounds. The seriousness of this operation is a common cause for post-operative wounds to appear and can be "as high as 25 percent," says Bitar. However, frequent dressing changes and additional antibiotics successfully heal any wounding.
The excessive removal of skin from the waist area yields positive results, albeit with temporary nerve complications. It is important for patients to understand the seriousness of the surgery, and the nerve injury complications that can occur. Since the amount of skin removed on the waist line is so extreme, many important nerves are cut in the process. These nerves provide sensation to the abdomen and buttocks, and can be temporarily destroyed after surgery. The result is the loss of feeling and/or numbness in these areas, and can last from months to up to a year.
Seromas are another complication seen after lower body lifts. After such a large removal of skin, fluids automatically begin to collect underneath, but can be treated with the application of drains under the skin during surgery. Seromas generally stop being problematic after surgery, but can be treated otherwise.
When many people succeed at reaching their desired weight through bariatric surgery and/or diet and exercise, cosmetic surgery can be used to put the finishing touches on a new appearance. However, candidates should thoroughly research each procedure before making a final decision. It should be noted that although cosmetic surgery will change the outer appearance, it is not guaranteed to fix any internal or psychological problems. Bitar says in "Plastic Surgery after Weight Loss," "Changing the outside, no matter how drastic in such a short period of time, does not change the inside."
