August 3, 2006
Skin Deep
Newly Petite in Skin Thats XL
By NATASHA SINGER
AS more severely obese people take drastic steps to lose weight, many are facing an unexpected hurdle in their struggle to slim down: rolls of loose skin that are heavy, uncomfortable and prone to rash and infection.
Body contouring, to cut away and tighten the excess skin that can develop after major weight loss, is one of the fastest growing invasive cosmetic surgeries in the United States. The procedures can be life-altering for those emerging from extreme obesity. For some, they can liberate a size 8 body from a size 22 suit of skin.
But these procedures have their drawbacks. The cost, which can run up to $100,000, is often not covered by medical insurance. And the series of procedures can take years to complete and leave lifelong scars and thats if all goes well.
Some health researchers are questioning whether body contouring is growing too fast, without a medical consensus on its risks and benefits. Further, doctors said some patients are unaware they may eventually need body contouring; they argue that plastic surgeons should consult with patients before their weight loss, so they are better prepared for how their body shape may change.
Socially, do you think we have done them any good when, after they have lost all that weight, they still look like elephant man with skin hanging down to their knees? said Dr. Rajiv Y. Chandawarkar, chief of plastic surgery at the University of Connecticut Health Center in Farmington.
Are they prepared for the pain of body contouring, Dr. Chandawarkar continued, for the surgical stigmata that can look like someone cut you in half?
Melissa Byrd, for one, said her doctors warnings never registered with her before she had gastric bypass surgery and lost 150 of her 300 pounds.
I saw photographs of people who looked like shar-peis, but I didnt really care then, said Ms. Byrd, 32, a textile saleswoman in Charlotte, N.C.
After her weight loss, she had so much extra skin on her trunk that she had to fold her loose stomach into her pants, she said. She later had body contouring during which Dr. Felmont F. Eaves III, a plastic surgeon in Charlotte, removed 11 pounds of skin, she said.
Last year, people who lost 100 pounds or more, through surgery or highly restricted diets, had about 68,000 body contouring procedures, a 22 percent increase from 2004, according to data extrapolated from a mail-in survey of doctors conducted by the American Society of Plastic Surgeons.
The boom is being fueled by procedures to combat morbid obesity in those who are 100 pounds or more above ideal weight. Doctors performed at least 112,000 stomach-reduction surgeries in 2003, a 740 percent increase over 1998, according to the Nationwide Inpatient Sample, a database of in-patient operations at hospitals compiled by the federal Agency for Healthcare Research and Quality. Al Roker of the Today show, and singer Carnie Wilson have publicly discussed having weight-loss surgery.
In a report last month, the agency said that 40 percent of patients who have obesity surgery develop complications within six months. Even so, surgeries like gastric bypass and lap banding are becoming popular routes for the extremely obese to improve health by shedding dozens of pounds.
Losing a few pounds does not cause sagging skin. But for many morbidly obese adults, the skin does not shrink with profound weight loss.
If you stretch a rubber band out for a second, it snaps back, said Dr. Robert B. Nemerofsky, a surgeon in Secaucus, N.J. But if you stretch it out and hold it for a week, the rubber band will not contract back to its original size.
Skin can stretch again if patients gain weight after body contouring, said Dr. Jeffrey M. Kenkel, vice chairman of plastic surgery at the University of Texas Southwestern Medical Center in Dallas.
For many people, living with excess skin is not an option. The cumbersome extra tissue can cause rashes, fungal infections, chafing, sores or back pain.
Doctors said body contouring can help restore patients health.
You take a person whose body has been distorted by massive weight loss and massive weight gain and you tighten residual skin to restore the patient to normalcy, said Dr. Gerald H. Pitman, a plastic surgeon in Manhattan.
Because many surgeries at once might be risky, doctors often stage these procedures over several years. Dr. Kenkels patients typically start out with body contouring of the abdomen, lower back and buttocks, followed by surgery on breasts and arms, and, finally, on the inner thighs, he said.
In June, Dr. Pitman operated on Rachael Hudes, a teacher from Honolulu, who had lost more than 100 pounds after weight-loss surgery in 2003.
The night before the surgery, Ms. Hudes stood in Dr. Pitmans office, a petite 5-foot-2 woman wearing extra-large skin. For more than an hour Dr. Pitman drew lines across her waist and pelvis where he planned to remove the extra flesh, without leaving scars that would show above bikini bottoms. When he finished, a series of lines that looked like a dress pattern crisscrossed her skin.
Some doctors perform belt lipectomy surgery in which they remove a circumferential belt of skin from a patients waist. Dr. Pitman said he prefers to combine several procedures a tummy tuck for the abdomen, plus a lift of each thigh and the buttocks because it allows him to better tighten the outer thighs.
The next morning, a sedated Ms. Hudes lay on her left side in an operating room at Tisch Hospital at New York University Medical Center. Dr. Pitman made an incision in her skin that ran from the middle of her lower back to the front of her right hip. Then he cut out a trapezoidal block of skin, weighing about two pounds, from her back and hip. Next, Dr. Pitman used a scalpel to lift the remaining skin from the muscle layer below, so he could pull the two sides of the gap together and attach them.
To do that, he worked like a surgical couturier tailoring a suit of skin to a unique form. He closed up the wound by sewing sutures into the fibrous layer of tissue beneath the skin.
When the right side was done, Dr. Pitman operated on her left side.
Two hours later, he began a tummy tuck in which he cut out four pounds of flesh from Ms. Hudes's abdomen. He also tightened her abdominal muscles by creating an internal corset made of sutures. Finally, he pulled down skin from her torso and up from her pelvis, fitting them like interlocking jigsaw puzzle pieces, and sewed them together. All together, it took eight hours.
A week later, recovering at her sister's house in New Jersey, Ms. Hudes said she was swollen, uncomfortable and in pain.
All this swelling makes me curious to know how small I am going to get afterwards, she said.
Recovery from body contouring can involve several nights in a hospital, pain, drainage tubes protruding from wounds, weeks off from work, swelling and permanent scars that run around the back and abdomen or down the insides of limbs.
Tracey Linke, a nurse in Greenville, S.C., who had body contouring after she lost 140 pounds on a restricted diet, said she was happy with the results but is still getting used to the scars.
What will I tell someone if they see me naked? Ms. Linke said. That I got bit in half by a shark?
Dr. Kenkel said patients must be prepared for an aesthetic tradeoff.
If they are looking for radical changes to their bodies, they have to be willing to trade scars for body shape, he said.
In addition to scars, body contouring can also cause fluid buildup under the skin, infections, open wounds and dead skin.
One woman in Georgia sued her doctor in 2003, alleging that body contouring damaged sensation in her left leg and foot. In the lawsuit, Steffany Obenour also charged that the surgery left her with different-sized thighs, a pubic area pulled to the side and a lopsided abdomen, according to court documents. In May, a court in Columbus, Ga., awarded Ms. Obenour $100,000 in damages.
Dr. Alfons Pomp, an associate professor of surgery at Weill Cornell Medical College in Manhattan, said the risks vary.
Some patients are going to have minor complications after body contouring, some major infections with big open wounds, said Dr. Pomp, a bariatric surgeon. Some are going to have blood clots or massive hemorrhages, and some are going to die from this. Results vary from practice to practice.
Most published studies on body contouring come from individual doctors who anecdotally describe their own work and evaluate results and complications in their own patients. That means doctors disagree on how frequently common problems like swelling and open wounds occur, said Dr. Nancy Birkmeyer, an associate professor of surgery at the University of Michigan Medical School.
We don't know if common means 10 percent, 25 percent, 50 percent of patients, or even more, will experience these problems, Dr. Birkmeyer said.
And then there is the expense. Dr. Kenkel said the procedures can cost up to $65,000 at his practice. Doctors often plead with health insurers to cover the most extreme cases where extra skin causes health problems.
Yet, Dr. Kenkel said surgeons soon may be unable to keep up with demand from weight-loss surgery patients.
Some doctors said that is all the more reason for more research. They suggest comparative studies involving multiple surgeons to help determine the best candidates for body contouring, to evaluate the aesthetic results and psychological consequences of the procedures and, most importantly, to calculate the risks.
Doctors should also consider the potential effects on quality of life, some medical researchers said.
We assume that body contouring surgery makes people feel better, said Dr. David B. Sarwer, associate professor of psychology in psychiatry and surgery at the University of Pennsylvania School of Medicine. But does that happen, and is that compromised if patients have complications and physical scars?
These procedures are so new, Dr. Sarwer said, that our enthusiasm for them has gotten ahead of the science.
Jean Hanff Korelitz contributed reporting for this article.
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