The financial officer of an organization to which I belong decided to have bariatric surgery. Bob (not his real name) needed to lose about 200 pounds and the operation, called the gastric sleeve, narrowed his stomach and decreased the production of ghrelin, a hormone that increases hunger. He lost about 190 pounds, significantly improved his food choices, and now exercises several times a week. But despite his success, and with it his improved health and energy, he told me that he was unhappy. “I had an image of myself as a thin person, which motivated me to always stick to the diet and work out. But now that I have lost all this weight, I feel encased in suit of loose skin. I have to force myself to go to the gym because I think everyone is staring at the skin hanging from arms and sagging down my thighs. I have to buy clothing in a size too large. My loose flesh prevents me from getting my arms in the sleeves of my jacket and zipping up my pants unless my clothes are baggy.”
Bob’s problem is not unique. Many patients who undergo bariatric surgery and are successful in losing very large amounts of weight are confronted with bodies distorted by excess skin. This is not a problem for those who lose much smaller amounts of weight. The skin regains its elasticity after being stretched, and regains its normal shape as it does, for example, after pregnancy. If large amounts of weight are lost very slowly, sometimes the skin regains its original shape, although this is less likely to occur in an older individual.
Surgery to promote rapid and massive weight loss, or extreme dieting and exercise, as seen in the television show program, “The Biggest Loser,” can leave pounds of skin behind. Although those of us who have not gone through the massive gain and then loss of weight might view the problem as merely cosmetic and a small price to pay for the weight loss, the problem is not simply cosmetic. (“Surgical solutions to the problem of massive weight loss,” Spector J, Levine S, and Karp N, World J Gastroenterol. 2006 12: 6602–6607.) In their article describing surgical solutions to help the newly thin deal with their excess skin, Spector and his co-authors point out that patients who have large amounts of skin draped over their limbs and the torso may be in chronic pain and the skin can be easily infected. Giodano reiterates their views in an article (“Removal of excess skin after massive weight loss: challenges and solutions,” Open Access Surgery 2015; 8: 51-60) and adds that physical impairment, including difficulty exercising or indeed even walking, and low self-esteem are some of the other problems caused by the excessive skin. Moreover, dieting and exercise are unable to bring the skin back to its original elasticity.
There is a solution. It is called body contouring, a plastic surgery that removes the skin, and by doing so, reveals the body shaped by the weight loss. Bob underwent several plastic surgical procedures over a period of many months but the results, giving him a body that finally revealed its nearly 200 pound weight loss, was attained only after a considerable cost in pain and money. He had to take time off from work, required a brief hospitalization for one procedure and, in his words, ‘”I won’t be taking a vacation for decades to pay for everything.” He justified going through this in part because he believed his professional appearance would be improved if he were able to wear clothes in the appropriate size for his weight and not to house his excess skin. But he admitted another more personal reason: “I was afraid that I would gain back the weight because I was so disappointed in how I felt and looked. In fact, my body was so distorted that I think I looked worse than when I was obese. ”
The failure of patients undergoing bariatric surgery to maintain their weight loss beyond one year post-operatively has been reported. (“Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy,” Golomb I, Ben David M Glass A, et al JAMA Surg. 2015; 150:1051-1057.) According to the Golomb et al report, a significant amount of weight is gained relatively early, i.e., within the first few years, and many of the patients did not lose enough weight to reach their goals before they started to gain again.
However, for those who did reach their weight-loss goal like Bob, would having body-contouring surgery support their efforts to maintain their weight loss? There is no answer. Indeed, the way to provide an answer would be to carry out a study comparing weight maintenance of patients whose excess skin is removed with patients who do not get the body contouring surgery. Both groups would receive the same nutritional counseling, personal training and psychological help so the only difference between the groups would be the removal of excess skin. Of course, the problem with such a study is that the results may show a positive effect on weight maintenance of skin removal. And then what? The cost of such operations is almost prohibitive for most people and rarely covered by health insurance.
But perhaps this will change. Bariatric surgery is paid for by many insurance plans because studies have shown that the medical costs of obesity are much higher in the long run than the cost of the surgery. If body contouring is shown to have a significant effect on preventing weight gain after bariatric surgery, then perhaps this too will be covered by health insurance.
The better solution, of course, is to prevent the excessive weight gain necessitating the surgery.