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from a really average woman who lost 100 lbs.
and works every day to keep it off.

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Monday, December 01, 2003  

Loose Skin
Tips for managing leftovers

Here's how it goes. You have fat cells. Eat more fuel than you burn, and your body stores the excess fat in your fat cells, which grow. Get more than 50 lbs. or so overweight, and you grow more fat cells, and store fat in those, too. All the while you're storing fat, your skin, like an elastic balloon, stretches over that fat, to keep you covered.

You're also stretching the little ligaments that attach the skin to the connective tissue and deeper structures in your body, which are under your fat, and over your organs and stuff.

When you lose the weight, your stretched-out skin and stretched connective ligaments sag.

If you're under 20 years old, if you have good genes, if you lose weight slowly, never smoke, keep stress under control, eat a nourishing diet, get plenty of exercise, and have less than 100 lbs. to lose, your skin, like a new balloon, may just snap back into place over time.

But if you don't have all of that going for you, if you have an old and tired balloon, you are very likely to be stuck with a bunch of extra skin after completing your weight loss.

It can be anywhere from disappointing to terribly disruptive to our social lives and self esteem to have these leftovers. Luckily, there are a bunch of things you can do to cope with them.

What you will need or want to do will depend a great deal on the amount and location of your extras. I have spoken with four doctors, all experts in their fields, to get help with understanding our options. Here they are, and some advice they each have to share with us:

David J. Leffell, M.D., Professor of Dermatology & Surgery at Yale School of Medicine, author of "Total Skin," (Hyperion, 2000)
*The skin is amazingly elastic, especially around the mouth and eyes, where it's opening and closing all the time. But our skin will naturally lose elasticity over time, which is why face lifts don't last forever. After weight loss, the body always wants to return to its healthiest state. That's the essence of how organisms survive in nature, fish or amoeba or human. Scars settle down. New collagen forms. Your skin will tighten some, but as you grow older, this process, the ability of the body to respond, slows. The body doesn't snap back as quickly or completely as many of us would like.
*The most conservative thing to do about excess skin is nothing. Wait and see. A year at least.
*Lipo can help pull skin up by creating fibrous bands of scar tissue, but it can result in puckering, dimpling. People have to be ready for that.
*The body does not auto-digest, or metabolize, excess skin. You haven't created new skin, but stretched out the skin you were born with.
*Do consult with specialists, and ask for a range of options. Consider each carefully. Do not rush a decision.

Dr. Robert Bell, M.D., M.A., Assistant Professor of Surgery and Director of Bariatric Surgery at Yale University School of Medicine
*Most of our patients have a great deal of weight to lose. They start with a BMI of 50 or more. So we see excess skin a lot, and the amount of it and experience of it are extremely variable. It's hard to pinpoint who will have how much at the end of their weight loss, and how they will feel about it.
*Most people who lose 100 lbs. or less don't have great issues with excess skin. The looseness may resolve itself over time. It's usually my patients who lose 200, 300 lbs. or more who consider surgery to manage the excess.
*For the vast majority of people, good underwear and clothing covers it all. You would never know they had excess skin at all.
*Insurance companies consider most excess skin surgery cosmetic, but in some cases, particularly at the tummy, where skin can form folds that encourage moistness, candidal rash becomes a problem, low back pain from supporting this excess skin becomes a problem, the insurance companies will agree to the medical necessity of the procedure. The company will want a lot of documentation.
*People who decide to have surgery are pretty determined to do so. The pain, recovery, cost, and risks of these surgeries are far higher than for bariatric surgery, so there's a lot to consider. But for many people, it helps their self esteem a great deal, and is a piece of the puzzle of an ongoing positive spiral of health.
*Fearing losing weight because of a fear of excess skin is an unreasonable fear. The experience of excess skin is nothing compared with the experience of diabetes, degenerative arthritis, sleep apnea, coronary artery disease, PCOS, and all the other weight-related diseases. It's simply unrealistic to worry about excess skin when considering a weight loss program.

Dr. Rhoda Narins, M.D., Clinical Professor of Dermatology, New York University, and President Elect of the American Society of Dermatologic Surgery:
*If you have just a little extra skin, liposuction can help tighten it. The focus for this sort of work isn't on removing fat, but on creating scar tissue that works in place of connecting ligaments to tighten the skin, pulling it back into place. Lipo for significant fat removal can also result in loose skin. So lipo works best for removing small amounts of fat to re-sculpt a specific area of the body.
*There are no crèmes or lotions that will help with either loose skin or with stretch marks. Some laser treatments are being evaluated for stretch marks, which can help with the red marks, but not the white. Not quite yet.
*For tightening just a bit of skin, we should keep our ears to the ground for treatments using radio frequencies to shrink the skin, not unlike the Thermage face lift devices currently available.
*For lots of extra skin at the tummy, breasts, arms, face, knees, surgery is it. The surgeries remove the excess skin, are time consuming to do, not inexpensive, require recovery time, leave scars. But you will know, through consultation, whether they would make you feel better about your new body.
*Though this work is considered cosmetic by insurance companies, Dr. Narin begs to differ. She says there is a clear psychic overlay to having this sort of work done. People who undergo this surgery feel much better about themselves, and that feeling can help bolster healthier habits in the long run.

Dennis J. Hurwitz, M.D., Clinical Professor of Surgery, University of Pittsburgh
*Factors determining the amount and location of loose skin seem to be age, speed of weight loss, smoking, exercise, poor diet, and stress. All of these factors, regardless of a person's weight, give us trouble with our skin.
*We do a comprehensive evaluation first, to determine the best approach, the logical approach for each patient. But for people who have achieved a BMI of 30 or less, and have multiple locations where excess skin bothers them, we have developed an 8- to 12-hour Total Body Lift surgery to shape everything in one session. This surgery is for highly motivated people who don't want to take the time for several operative sessions.
*Cost of this surgery can range from $10,000 to $30,000, depending on what is being done.
*Patients do have good luck getting financing for this surgery. It is tax deductible.
*We do use Endermology, or treatments with a fat rolling/suction machine, for light cases. It helps a bit with the appearance of loose skin, cellulite. A mild difference. It's a comfortable procedure we also use with post operative patients to help speed healing.
*In my 26 years of practice, I have never experienced any work so gratifying, that does as much good for people, so dramatically, so quickly. People can be depressed and angry and dysfunctional in their lives as a result of this excess skin. After surgery, they find it much easier to resume business, social, and intimate contacts with far greater confidence.

That's what the docs tell us. See their websites and for clear descriptions of the various surgeries available.

Each of the doctors agree that people who have lost a significant amount of weight should wait for at least a year for their weight to stabilize and for skin to adjust before evaluating options.

When asked to speak to rumors circulating on the Net, none of the doctors had any knowledge of "skin donation" deals, where people with excess skin could donate it to burn victims to cover the cost of their surgeries. But none thought it was a completely crazy idea, and suggested speaking with burn clinics close to you if you'd like to find out more.

Discovery Health has been airing a program showing Val, a woman who has lost more than 300 pounds, undergo a lower body lift. The show will air several more times this year. The effect on people who watch it can be overwhelming. It's quite graphic, be warned. But it's truthful about the surgery, the recovery, the sheer investment of energy, nerve, and dollars to see it through. Visit for schedules.

Discovery is also taping one of Dr. Hurwitz' Total Body Lift procedures, with air dates tentatively planned for Spring, 2004. The November 9 "People Magazine" featured a Total Makeover cover story profiling one of Dr. Hurwitz' patients.

My own experience has been good and lucky. After losing 110 pounds at age 43, while I do have extra skin around my tummy, it isn't more than most moms have after giving birth, and previous scars from childhood surgeries actually work to hold my tummy flat. Though my arms have been a bit flappy, that flappiness has diminished a good bit over the past two years, so I feel fine about exposing them. Loose thigh skin is "cured" by candlelight and my husband's diminishing eyesight. My under-chin flap is so dramatically preferable to a double chin, that it can't begin to bother me. Everything else is well managed by day by my friend Lycra, though there is a huge market for yet-to-be-developed, lighter-weight Lycra underthings going untapped in the world.

The upshot. Don't let the leftovers scare you. Your health is more important than any other thing. And wait awhile before evaluating your options.

Total Body Lift at Dr. Hurwitz' clinic
Dr. Narin's clinic
Discovery Health: Trash Can of Skin Schedule
U.S. folks, find a surgeon near you, review surgeries here
Thermage radio-frequency face lifts

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