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You’ve Lost the Pounds, Now How Do You Lose the Skin?
by: Dr. Bunkis
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There are over 500,000 U.S. citizens who die from obesity each year.
There are over 500,000 U.S. citizens who die from obesity each year.

Q: I went to a bariatric surgery clinic in San Diego, had a gastric bypass and lost one hundred and forty five pounds. My weight has stabilized but I find it difficult to look at myself without my clothes off. The San Diego clinic told me I’d need repeated treatments to get rid of my excess flab and that’s too far for me to drive – tell me your experience with post bariatric patients and how you could help me.

-Bill G Dana Point, CA


A: Twenty five years ago, it was rare to have a patient walk into a plastic surgeon’s office after substantial weight loss. But these days, we routinely see patients at Orange County Plastic Surgery who have lost in excess of one hundred pounds. About three quarters of the massive weight loss patients we see did so with the assistance of bariatric surgery – such procedures have been designed to either decrease the size of the stomach pouch or some variety of “bypass” which shunts food down the intestines quicker without absorbing as many calories. Since you fall into the post massive weight loss category, you are first to be congratulated for losing so much weight! You have done your general health a massive favor! Unfortunately, most skin does not go back to its pre-stretched condition. The part that is most obvious to most patients is the skin excess in the abdominal area, but removing this alone rarely gives a patient a satisfying result as they will next focus on the loose skin of the back, thighs, breasts, arms or face. To get a total correction, one that requires two or more procedures, most post weight loss patients desire to have the excess remaining skin from backs, thighs and arms removed, their breasts uplifted, with or without an implant, or reduced, and lax facial skin tightened.

You are not alone in this struggle to loose weight. There is an obesity epidemic in the United States. 11-15 million Americans are morbidly obese, a 200% increase in the last 20 years. According to a report from the Centers for Disease Control and Prevention, obesity became the leading cause of mortality in the United States in 2005, with a death toll of 500,000 per year, surpassing the death toll from tobacco use. As a result, the popularity of bariatric weight reduction operations like gastric banding and gastric bypass surgery is soaring (approximately 200,000 cases per year). The health benefits to such patients are measurable but many are horrified by the amount of loose skin they see over their legs and thighs, abdominal and back, breast, arm and facial areas. Such patients frequently end up at Orange County Plastic Surgery to seek the expertise of Dr. Bunkis and his staff.

Here is an overview of what to expect if you decide to go ahead with a resection of your excess skin:

Preoperative Preparation
Bariatric surgery is just the beginning of an ongoing journey toward weight loss through lifestyle changes. Patients have to learn how to eat differently, exercise more - and keep adjusting their ward robe as they shed pounds. Most go through this journey with the assistance of a support group consisting of many individuals including the bariatric surgical team, dieticians, personal trainers, others who have lost weight and some include plastic and reconstructive surgeons. Once weight loss has stabilized, most patients wait a year or so before considering another round of surgical procedures to correct the global skin laxity that almost invariably is associated with significant weight loss. Associations such as the American Society of Bariatric Plastic Surgeons' (https://www.asbps.org/user_details.php?detail_id=551) can help patients find a qualified surgeon to help them on this long road to recovery.

Once you have decided upon a surgeon, you should visit your surgeon as many times as it takes to have all your questions answered. Most people require a head to toe type of reconstruction but it is necessary to break the number of procedures into manageable portions that can be done safely with any given procedure lasting six hours or less – longer procedures are associated with an increased incidence of complications such as blood clots in the calves and infections. Most patients begin with addressing the abdominal area with a belt lipectomy (a resection of abdominal and back skin). At the same sitting, many will also do their arms or breasts, and then return after they have healed for a tightening of the thighs and perhaps a face lift. At your final preoperative visit each time, you will confirm that you understand the procedures to be performed, and that you accept the risks of the procedures you have chosen. You will be given prescriptions for surgical soap that will be used before surgery, as well as for pain pills and antibiotics. Laboratory test results will be reviewed - many bariatric patients are a little anemic and iron tablets may be recommended. Patients will be asked to stop smoking a month prior to surgery in an effort to maximize your body’s ability to heal following the surgery - and hopefully the patients will use this opportunity to quit smoking permanently.

Patients are asked to scrub the surgical sites with a special soap for ten minutes the evening prior to surgery and a final time the morning of surgery before leaving home. This step, along with taking antibiotics after surgery, will lower the possibility of an infection occurring after surgery.

All patients should avoid all anti-inflammatory drugs (Ibuprofen (Advil), all aspirin products and excessive quantities of Vitamin E) for two weeks before surgery, as these substances inhibit the clotting mechanism and increase the chance of unnecessary operative bleeding.

Surgical Procedure
The operations are all performed in an outpatient facility under a light general anesthetic, either at the Laguna Surgery Center in Southern California or at the Tracy Surgery Center in Northern California. A well trained, board certified anesthesiologist will ensure your safety during the procedure.

Depending on the part of the body to be worked on during the current procedure, incisions will be made as discussed with you preoperatively, and the excess skin and fat will be trimmed. Sometimes it becomes necessary to suction some of the excess fat that can not be resected, but there is a limit to how much fat can be removed without jeopardizing the viability of the overlying skin flaps. Silicone rubber drains are frequently inserted prior to suturing the wound closed to prevent excess fluid from collecting under the skin. This drainage usually subsides in a week to ten days but may take up to a month or even longer to stop. In addition, small catheters which infuse local anesthesia into the surgical field to decrease post operative discomfort may be inserted – these are removed 2-4 days after surgery.

Postoperative Recovery
Most patients will spend the first night or two with a registered nurse, usually at a hotel near the surgery center. Thereafter, the patients will be comfortable enough to go home with an adult family member or friend. We have two basic rules after almost any surgery we perform. First of all, even if you do not have discomfort, take it easy and rest the first two or three days after any procedure - take a walk frequently to avoid the possibility of potentially deadly, blood clots forming in your calf veins, but don't take on any other tasks. After the third day, patients are all over thee map in comfort levels - each patient should listen to their body and do what is comfortable, avoid anything that is not! All patients can walk around but no one will be able to run in the first week. Those who wish to run or do a sit up or lift a weight should do so whenever they are comfortable. Generally, it takes six to eight weeks before most patients can resume all their prior vigorous activities. Swelling in the surgical sites takes up to six months to go down and the scars could take a year and a half to finally mature and fade. If a patient keeps their weight down, these procedures will never have to be repeated.

I could not begin to tell you what your best option would be without evaluating you in person. Please call us at (949) 888-9700 and ask the staff to arrange a complimentary consultation for you and I will be happy to give you my best opinion as to your options. But to leave off, here is a before weight loss patient and a final follow up photo after I did her reconstruction in multiple stages.


949.888.970 | 30212 Tomas Ste. 275, Rancho Santa Margarita, CA 92688 |
www.ocps.com


As Medical Director of Orange County Plastic Surgery, Juris Bunkis, M.D., F. A.C.S. brings 30 years of surgical expertise to our communities. Dr. Bunkis is a Harvard trained, Board Certified Plastic Surgeon and Member of numerous prestigious organizations including the American Society of Aesthetic Plastic Surgeons, The International Society of Aesthetic Plastic Surgery, the American Society of Plastic Surgeons and the California Society of Plastic Surgeons. Dr. Bunkis, a former faculty member at the University of California, San Francisco, has published more than 40 scientific publications, abstracts and book reviews, and 17 book chapters in plastic surgery text books. For questions or advice, please contact Dr. Bunkis directly at Bunkis@ocps.com
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