Once the surgery has been performed and the patient recovered from the surgery itself, the patient's nutritional status must be monitored carefully, for with the marked decrease in calories there will be an accompanying decrease in vital nutrients, vitamins, etc. It is ideal for a nutritionist to follow and advise the patient. Weight loss will be variable with each patient, for dietary cheating is still possible. Most responsible physicians will recommend that observation for a minimum of 18-24 months is mandatory before embarking on any reconstructive plastic surgery. It will take that long for the patient to stabilize at a certain weight and to stabilize their metabolism as well.

After a patient has stabilized at a reasonable weight, they are then candidates for plastic surgery. It is an axiom that skin and subcutaneous tissues cannot possibly tighten up after massive weight loss--too much elasticity has been lost and too many ligaments stretched out. It's as if a normal person had put on a set of clothing ten sizes too large! There is no exercise that alone will improve the lax skin. Weight losses of over 100 pounds or more will result in hanging, flabby skin of the neck, arms, chest, abdomen and thighs. An overhanging apron of abdominal skin and fat down to the mid thighs is not uncommon and will clearly result in difficulty walking and finding appropriate clothing. Lax hanging thigh skin will also hinder movement.

Therefore, skin and subcutaneous tissue resection is necessary and no portion of the body is spared--from the neck to the knees. For example, hanging neck skin will require a neck lift or a facelift. Flabby, hanging arm skin ("bat-wing" deformities) will need excision (brachioplasty). Breasts (on both men and women) will flatten and sag, requiring a variety of operative techniques to lift and shape them. Women occasionally require a breast implant as well to replace the volume lost by fat atrophy.

The skin of the trunk, both anteriorly and posteriorly, will hang in festoons dictated by specific ligamentous points of attachment. Multiple procedures have been devised to address individual problems--tummy tuck (abdominoplasty), panniculectomy, belt lipectomy, and whole body lifts are among some alternative methods of treatment.

Treatment of the loose, hanging skin of the thighs is most challenging--we do have some procedures but the results are not very gratifying. These include a thigh/buttock lift, a thigh tightening and an inner thigh lift. The result is like pulling up a pair of pants. There are no operations for lax, over-hanging skin just above the front of the knee.

The ironic part of all of this is that most of the original surgery is done laparoscopically--with tiny incisions and resultant minimal scars. The cosmetic, plastic surgical part of the process, in order to remove the excess lax and hanging skin, involves massive incisions and scars, sometimes completely encircling the torso. Fortunately, most previously obese patients are more than willing to trade multiple scars for a body which can fit cleanly and comfortably into smaller size clothing which is available off-the-shelf.

It is obvious that there are a large number of areas which have to be addressed surgically, and this will require multiple, staged operations. I frequently ask my patients to prioritize them, so that we can develop a surgical "game plan." Then, procedures are performed--some ambulatory and some in-patient--over a period that may last up to two years or longer. Management and treatment of the resultant scars will require periodic evaluation by the plastic surgeon, and sometimes secondary procedures are necessary to "fine-tune" the surgical results and contours.

The only bad news about all of this is that despite the fact that the original surgery for obesity is usually covered by insurance, virtually none of the reconstructive plastic surgery is covered, for it is considered cosmetic. There is some movement towards requiring insurance companies to cover the cost of reconstruction, but they resist. Their rationale? Obesity is a killer (and therefore deserving of insurance coverage for treatment), but the now no longer obese individual will not "die" of loose, hanging, flabby skin--that is "cosmetic." They simply refuse to accept that overhanging skin is a natural and predictable result of the original treatment--and therefore should be covered by insurance as well. The cost for plastic surgical total body make-over? Approximately $50,000 - $75,000 for some individuals.

At the end of the line, however, one cannot possibly imagine the immense psychological boost these patients obtain when they are healthier in every way, able to walk comfortably, to fit into reasonable clothes and to sit in a normal theater or airplane seat without literally over-flowing into adjacent ones. Their general health, their energy, their self-esteem and self-image are immeasurably improved--and they emerge--like pupa to butterfly--as new individuals. It is truly a life-changing experience.

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