Plastic Surgery After Massive Weight Loss

Uncategorized |  Dr Eddy Dona

Tue 12th May 2020

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Although plastic surgery has many subspecialties—including craniofacial and maxillofacial surgery, microsurgery, reconstructive surgery, cosmetic surgery and surgery that address issues of burns and skin cancers—a large subspecialty is the plastic surgery required after massive weight loss. The term ‘reconstructive surgery’ applies to all the subspecialty within plastic surgery, including some ‘cosmetic surgery’ procedures. In Australia, all plastic surgeons are classified as Plastic and Reconstructive surgeons. Personally, I am a member of the Australian Society of Plastic Surgeons, whose motto is Corpore Mens Melior Refecto (‘the mind is better when the body has been restored’). Reconstruction means to restore to a state or to create a state that is ‘normal’; ‘normal’ means something that is functional or acceptable to an individual’s race, sex and age. ‘Normal’ is also in the eye of the beholder and the mathematical definition of average cannot be applied to the human form when defining normal.

The most common cause of massive weight change is pregnancy. Another common occurrence of massive weight loss exists in individuals who are carrying a great deal extra weight and who lose weight through diet and exercise. Finally, individuals who require surgical assistance to lose weight—such as lap band, gastric sleeve and gastric bypass surgery—represent another common occurrence of massive weight loss. No matter the cause, individuals who have lost a massive amount of weight experience the same issue—their bodies become smaller but their skin does not. Skin does not contract, shrink or wrap around a smaller body. Metaphorically, excess skin represents the former self—or an old dress. Individuals who have lost a massive amount of weight become smaller, fitter and healthier but they are essentially wearing a dress that is too big. The bigger the loss, the baggier the dress.

This can often cause or contribute to ‘yo-yo’ dieting habits—a vicious cycle of weight loss and weight gain. Individuals who lose massive amounts of weight do so through discipline, diet and exercise. However, when they look in the mirror they often still view themselves negatively due to the excess skin that hangs from their bodies. This can lead to individuals not only giving up and reverting to their old dietary habits but also developing a more concerning issue—depression. So, what do you do when you have a dress that is too big for you? You cannot throw away your skin but you can have it tailored. As your surgeon, I can tailor your skin to fit your body.

I like to compare the surgery required after massive weight loss to dressmaking. In dressmaking, you remove material and run a seam; in surgery, you remove skin and create scars. Creating scars improves contours. Therefore, creating more scars can create better contours. Of course, reconstruction involves far more than skin, but this is the simple way in which I explain reconstructive surgery to my patients—that surgeons tailor their patients’ skin to fit their body.

Actual tailoring involves materials that do not have much stretch. When you purchase a custom-made dress, you typically have a fitting so adjustments can be made to ensure that the dress fits perfectly. Although surgery after massive weight loss can be compared to dressmaking, it is much more complex. Skin and tissues are not rigid—they swell, stretch, shrink and sag. Additionally, the body beneath the skin also changes, which is especially true during the first few months after surgery. Therefore, as a surgeon, I craft, sculpt and reshape things that are 3D, and not static. I also ensure that I do not make things too tight because that can result in serious problems with how a wound heals and breaks down. After the initial post-surgery swelling starts to decrease and the skin settles into position, it is normal for your skin to not feel as tight as it did initially. Therefore, it is not uncommon to require further minor surgery to fine-tune the results.

Although massive weight loss affects skin in every area of the body, the four common areas are the arms, the breasts and chest area, the stomach and the thighs. However, there is a limit to how much can be achieved in one day so you typically cannot have every procedure done at one time. Combinations that can occur in the same surgery are the breasts and stomach and the breasts and the arms. For some individuals, I might combine the arms, the breasts and the stomach. However, operating on the thighs is something I never combine with another area because it is a big operation with its own potential and significant issues. Basically, we start with the areas that most concern an individual and then we continue in stages depending on the degree of concern and other considerations such as lifestyle and financial constraints. The minimum time period between each surgery is three months.

My job is to educate my patients. We have real discussions about what they are dealing with and what needs to happen to ensure they reach their goals. I have a YouTube channel with an extensive video library showcasing all my surgeries. Many of my patients have observed my surgeries and followed my YouTube channel for a long period so they are familiar with the surgeries and know what is involved. I also never trivialise an operation. Although it would be easy to simply show before and after pictures, every surgery carries risks that patients need to understand. Regarding consenting, although all operations have similar post-op course issues and potential complications, each operation has a unique post-op course and potential complications that I must bring to my patients’ attention, which are things we discuss during our consultation. I also clarify any issues they may have.

Do patients who have lost a massive amount of weight experience medical or cosmetic issues? Although there are explicitly physical problems associated with having excess skin, other issues are implicitly physical. Can psychological problems be physical? The body and mind are intertwined and while psychology and psychiatry are large fields of medicine, where is the distinction? When do we say that the surgery to address these concerns is purely cosmetic? Referring to my earlier definition of ‘reconstruction’, all surgery required to address these patients’ concerns is without question reconstructive surgery. As a secondary benefit, they are going to look better. However, the primary purpose of the surgery is not cosmetic but reconstructive.

Any form of reconstructive surgery is complex and carries risks. However, to compound these risks, the skin and tissue quality of many of these patients is poor, which increases the potential for issues such as poor wound healing. This leads to a higher risk of wounds breaking down with skin and tissue loss. Therefore, there is a high risk of further surgery being required in the postoperative stage to address these issues. Higher-risk patients must accept the possibility of experiencing wound healing issues that will warrant further surgeries and downtime. This is all part of the consent process discussed at length prior to surgery.

Overall, the surgery required to address the issues experienced by patients who have undergone massive weight loss is total-body reconstruction. For a surgeon to succeed at this type of surgery, they must appreciate anatomy and ‘normal’ aesthetics. However, many surgeons avoid these patients because they are considered difficult and ‘not worth the risk’. Such surgeons typically chose ‘easy’ surgical problems to address. Additionally, many surgeons lack the technical and artistic skill set to manage these patients, which is another reason why they choose to not treat them. Any surgeon can cut and sew. However, to be a master reconstructive surgeon requires an artistic flare to sculpt, reshape, restore and reconstruct a living work of art.