Ways To Lift & Tighten Loose Skin After Losing 100+ Lbs

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:09):
Hey, Dr. Koehler.

Dr.Koehler (00:10):
Hey Kirstin.

Kirstin (00:12):
You got any ideas for today's podcast?

Dr. Koehler (00:15):
I leave that up to you. What do you want to talk about?

Kirstin (00:18):
Oh, okay. Well then let's talk about massive weight loss because that is a hot topic lately.

Dr. Koehler (00:25):
Okay.

Kirstin (00:26):
So I think massive weight loss can be something that's already going to be a life-changing event for a patient, but then taking it to the next level of having extra skin removed. Can you think of any stories that come to mind about a patient like that?

Dr. Koehler (00:39):
Yeah, I have a patient that I treated, it was probably close 15, 20 years ago, but she had had a gastric bypass. She'd lost a bunch of weight. She had diabetes and high blood pressure and all these things, which are all better now that she had her gastric bypass. So I was having this conversation with her and I said, oh, well, you must be really glad that you had this done. And she just, without like, no expression on her face at all, she just looked at me and she goes, really, honestly, at this point, I can't really say that. And I said, really? And she goes, yeah. She goes, honestly, if I'd have known that my body was going to look like this after it was all done, I don't know. I think I would've rather lived with the high blood pressure and everything else because she's got all this loose skin that she hates.

(01:25):
And so anyhow, we did several surgeries on her and once it was all done, she absolutely was glad that she went through the process. But I think that's where some education from the people who do those types of bariatric procedures, that has to happen with the patients because although they may affect their health in a positive way, they're going to be left with some stigmata of that surgery that they're going to have to deal with. And either if they can't afford it, they're going to have to live with it. So it's kind of a big deal, wasn't what I just sort of thought, oh, you've lost all this weight and your health's better. You must be so excited about it. And no, she wasn't.

Kirstin (02:02):
Yeah, I know you hate me talking about TikTok and social media and whatever, but that is a big thing with people who have massive weight loss via losing it on their own or with gastric bypass or stuff like that. They just don't expect all of that extra skin that they're going to have. And it leads to problems like yeast infections and just skin irritations and stuff like that. And so sometimes if you're going to have massive weight loss like that, you've got to be able to take care of the skin afterwards.

Dr. Koehler (02:32):
Yeah, no, I mean it's definitely, I think sometimes people don't realize to what extent that is going to be, and it varies from person to person. I've always said if you ever watched that show that when it was on the Biggest Loser, you can see people that have pretty significant amounts of weight loss, but their skin does, and it tightens up all right. And then other people it doesn't. And so some of that is just a function of your genetics and your skin elasticity and stuff like that. And certainly your skin does better when you do it naturally than when you do it through certain types of surgical procedures like gastric bypass.

Kirstin (03:06):
Is that because the weight loss is rapid with something like that versus gradually losing it?

Dr. Koehler (03:10):
I think that may play a small role in it. I think definitely when you lose the weight fast, it takes some time for your skin to sort of contract because it will we'll put tissue expanders in people sometimes to grow skin for surgical procedures. But if you take that expander out, it's going to slowly, it takes time, but it'll shrink back down. So yes, the speed at which you lose the weight probably plays a role. But really the bigger thing, when you look at procedures like gastric bypass, the way that operation works is they make the pouch of your stomach smaller, but then they also rearrange things. And so you don't absorb vitamins and minerals and certain things the way that you're supposed to. And I can tell you in my personal experience that when I do, let's say a tummy tuck on somebody who's had a gastric bypass versus somebody who just lost weight on their own, the skin quality and the skin thickness is dramatically different. If you didn't tell me anything about the patient and I was doing a surgery, I mean, I'll bet I could pick out the bariatric patients probably nine times out of 10 just because of the skin thickness and the skin, how it manipulates. Not always, but I see it pretty commonly.

Kirstin (04:21):
That's interesting. What about people taking this skinny shot that we've heard so much about lately? Are you seeing a lot more people with loose skin than you used to?

Dr. Koehler (04:34):
I don't know that I'm seeing more. I mean, we've seen it for a long time and people have lost weight on their own and they have the same issues, but I guess you hear about it a little bit more. It certainly, people talk about ozempic face and stuff like that where people have lost weight with these GLP one agonists. So it's a shot. There's some that are pills, I believe too. But anyhow, it's a shot that people get once a week and it's been pretty effective. But the verdict still out on this. I mean, I think we were talking about it the other day. It was FDA approved though ozempic was approved for people who are obese and chronic weight management issues. But there's a lot of people that don't really meet that criteria that are using it for weight loss too. But it slows down your gastric emptying.

(05:22):
It makes you feel full quicker, and it helps and it helps with, and the main reason that drug was brought to market was for type two diabetes. So it helps with your insulin secretion and it helps people with their blood sugar so they don't have weight gain and spikes in their blood sugar as well. But anyhow, that drug has been very effective. But we're coming to realize there are some problems, and actually one I'd like to bring to the attention of everybody listening here. So we have surgery patients that are coming in for various procedures, and it may not even be because of loose skin. I mean, they could be coming in for a rhinoplasty, but they may be on a drug like ozempic. And so now what we've realized, and we didn't personally ever have an issue, and I don't actually know a doctor that's had an issue, but it's definitely happened somewhere because it's come to people's attention that because that drug delays gastric emptying, it puts people at risk for aspiration at surgery.

(06:15):
So when anesthesia puts you to sleep, it's possible that even though you didn't have anything to eat or drink for six hours before surgery because your stomach is not emptying the way that it should, you might actually have a full stomach when you're supposed to have an empty stomach. And when all those muscle and everything relax, when they give you the medicines to put you to sleep, those gastric contents can come back up and it can get into your lungs and it can cause pneumonia and a lot of other issues. So we now tell patients to stop all of those drugs for two weeks before surgery. Now, perhaps if it's in a diabetic patient, depending on what that really is, taking it for their diabetes, I mean, we might go a week ahead of time, but people are taking it just for weight loss. We want 'em off of it for two weeks so.

Kirstin (07:02):
Yeah, these are elective surgeries. We want you to be as safe as possible.

Dr. Koehler (07:06):
Yeah. Absolutely.

Kirstin (07:07):
Yeah. Okay. So for somebody who has lost a lot of weight and wants to come in and have surgery, is there a certain amount of time that you would recommend them having a stable weight before they come get, say like a tummy tuck or back lift or something like that?

Dr. Koehler (07:20):
Yeah, that's a good question. So if somebody had a gastric bypass for them to kind of reach a stable weight is typically around 18 months. So a year and a half. And typically on those patients, I'd say, look, when your doctor kind of says, Hey, you've hit your goal weight and we feel like this is a weight we want you to be at, then that's a good time to go ahead and let's consider doing some body contouring procedures. But if it's only been nine months since your gastric bypass, I mean, you still may have a lot of weight to lose. So we don't want to start doing that right now. Now, if you're talking about some of these GLP one agonists, I mean, it depends. If you say, well, I've been on it for a year now and my weight hasn't changed in three months or four months, I mean, okay, well, maybe we're ready to go.

(08:03):
But if you're still having significant weight loss while you're on that medication, then yeah, we want to wait until we're close to the weight. Now, patients who come to me who are not on those drugs or not had surgery and they're just a little bit overweight and they go, Hey, I'm planning on losing weight. My first question is, well, how much weight are we talking if it's within 20 pounds? I typically tell people, look, 20 pounds is probably not going to make a difference. We can do your contouring, and if you lose that additional weight, you're not going to be left with loose skin. But if we're talking 50 pounds now all of a sudden, maybe that's a bigger deal and there's not an actual number, but that's the number I'll typically throw out. I'm like, look, if you're within 20 pounds or where you plan to be, then let's do it. That's for people who are just losing weight on their own. But for these other surgical procedures, I want their weight to kind of be more stabilized because I don't know where they're going to end up.

Kirstin (08:55):
Yeah. Is there a certain BMI guideline that you have for people wanting surgery?

Dr. Koehler (09:00):
Yeah, it's changed a little bit. So I mean, it just sort of depends. I mean, there's not, all I can say is this. When your BMI is over 30, we know, and by the way, people who don't know what A BMI is, it's a number that's calculated based off of your height and your weight. And these numbers, although they're helpful for doctors to use, is not really a, I won't say it's accurate, but it's not perfect because my BMI is a little higher than it should be, but I've been working out, I feel like I got more muscle mass. So no, but it's a proportion. So if you see people who are bodybuilders and stuff like that, if you calculate their BMI, they will come up as being obese, and you'll look at 'em and they're like, they have a body fat of 11%. They're not obese.

(09:44):
Now they don't meet those tables. And those are the kinds of people that make those measurements. Maybe not correct, but for the most part, when you hit A BMI of 30, your risks increase at surgery. And what would those risks be? Well, the risks of getting a blood clot, the risks of your incision opening up, the risk of getting an infection. So there's a lot of risks that start to occur. And then if you have other risk factors like smoking or other history of family history of clotting disorders, all those things kind of add up. So there's not one thing. I may have somebody who's A BMI of 33 and be yet no problem, but I could have another patient, A BMI of 33, but they have maybe some other factors going on and where you're not a good candidate. So it's not just that, but typically we like to do for outpatient stuff that I'm going to do in my office, it's going to be under 35.

(10:37):
If it's over 35, I'm typically doing it at the hospital. So anyhow, you can do surgery on higher bmi, but those people need to be educated. They're at higher risk for problems. And so when people say there's some doctors, their BMI cutoff is 30 for certain procedures, and they're doing that not because they don't like you or whatever, it's like they just don't want to have to deal with the complications because they know that the risk is higher. And you can tell people, oh, we're going to do this procedure, but your risk is higher for whatever. And sometimes people that goes in one ear and out the other and they're like, yeah, that's probably not going to happen to me. I'm okay. Let's go ahead and do this. So anyhow, each doctor is different. There's not a standardized cutoff by any means. I mean, sometimes we end up doing procedures on higher BMI patients. It makes sense.

Kirstin (11:28):
If there are people with massive weight loss that come see you and want or request multiple procedures because they have lots of extra skin, can they get that done all at once?

Dr. Koehler (11:41):
Also, that's a case by case basis. So depends again on a couple things. So if you had a gastric bypass surgery, and I told you that those patients suffer from different problems, they don't absorb nutrients as well, and they don't absorb iron and other things as well. So a lot of those patients walk around with a lower blood count, and so they're in a little bit anemic. So that may play a role into how many areas I plan to do surgery, because I also don't want to end up having to give them a blood transfusion after the procedure. So we factor in the blood loss where their blood count starts. So maybe a bariatric patient, we have to maybe do it a little slower. Another patient maybe we could go, oh, if their blood counts are good and they're healthy and they have no other health issues, we could do maybe a couple different areas. Again, we talk about the risk of blood clots in surgery. One of the risk factors for blood clots in surgery is the length of time of the surgery. So if you're doing really a longer procedure and they have other risk factors, that's why we may tend to try to break it up a little bit.

Kirstin (12:46):
Is there a certain amount of time in between if you do have to split some surgeries up, would you wait two weeks, six weeks, 12 weeks?

Dr. Koehler (12:55):
Yeah, it depends. Usually it'd be at least three months typically. And there can be some advantages to doing that too. And it's not just like when you could do it, you could probably, and some people, you could probably be like, okay, look, they did great. We didn't have much blood loss. They're probably, their blood counts are fine in six weeks. You could do it. But there's a practical part here too, because as people go through the healing process, sometimes when we go back, we're like, okay, we need to tweak things a little bit and we want you healed enough that if we want to adjust a scar or something else, that we can take advantage of that second surgery to take care of any issues that might have occurred with the first. Because sometimes people do need some touch-ups, so sometimes there can be benefits to spacing it out. But three months is probably kind of standard for me.

Kirstin (13:37):
Okay. I'm on all these Facebook cosmetic surgery groups and they're constantly talking about tummy tuck, 360 extended tummy tuck, back lift, dah, dah, dah, dah. So are all these things the same thing?

Dr. Koehler (13:51):
No. Yeah, there's different terms and sometimes what one doctor calls an extended tummy tuck, if somebody may call something else. But basically the issue there is like a standard tummy tuck kind of just goes from hip bone to hip bone, an extended tummy tuck, what might be on a bigger patient, where now they've got some fullness along the side. And so instead of doing a complete body lift where we go 360, which is what you called it, typically called a belt lipectomy or a body lift. So for somebody that's kind of in between, we might just do what's called an extended tummy tuck where they just need a little more taken off of the side. But if they also have some laxity in the buttocks, then really we need to go all the way around. And then that's a body lift. So all of those procedures, whether it's an extended tummy tuck, a regular tummy tuck, or a body lift or a belt, they all do the same thing for the tummy. We're going to tighten the muscles. All of them are a tummy tuck. The difference is as we extended or work our way around, we're starting to address other areas that a traditional plumbing tuck doesn't really address.

Kirstin (14:58):
So, or those are surgeries for the trunk. Are there other procedures that you can do to help with loose skin after a massive weight loss on arms, legs, that face?

Dr. Koehler (15:09):
Oh, yeah. Yeah. So yeah, the classic things are you're going to have breasts, tummy, arms, and thighs. Those are going to be for the body stuff. I mean, that's what we address. And typically, for most people who are experiencing weight loss, first thing that they want corrected is their abdomen or their belt lift or tummy tuck. And the main reason is that a lot of people, that's where they carry most of their weight. And so that's also where most of their laxity is. That's not true for all of my weight loss patients. Sometimes people come in and I'm looking and I'm like, they've got lots of laxity on their abdomen, but they're like, I really hate my arms, do my arms. So I mean, it's not a hundred percent, but a lot of people going to the abdomen is sort of the first place that people do.

(15:55):
And a lot of times we'll do that in conjunction with the breasts. So that might be a breast lift, might be a breast lift with an implant. So that's what we typically do first. And then arms and thighs kind of get done, usually second and third. And I usually leave the thighs to the end, mainly because we can see some benefits if we do a body lift, you'll see improvement on the thighs just with that. So sometimes, depending on how much laxity they have, that might be enough to make the patient happy. But if not, we'll do a thigh lift and thigh lifts. The one downside is, is that area, the skin on the inner thigh is thin, and a lot of times if we're taking a large amount off, it's under tension and it can be a little higher rate of skin breakdown compared to, let's say a tummy tuck.

(16:39):
So anyhow, so we want your procedures to be as positive as possible. We don't want to start off with a procedure that you end up with a wound breakdown. I mean, it happens and some people do fantastic, but that particular procedure does carry a little higher rate of skin breakdown compared to the others. And then when it comes to face, that's a whole separate kind of area. But definitely the thing I hear from weight loss people is when they lose that fat in their face, it makes 'em look older. And I would agree, and it's, they've lost so much volume in their face. When you think about a young person, they have a full more round face.

Kirstin (17:16):
Would you prefer to do any of those procedures at the hospital versus at the office, or is it

Dr. Koehler (17:23):
Depends. Again, all my answers are, it depends. But the body lifts

Kirstin (17:27):
Typical man.

Dr. Koehler (17:29):
Yeah. It just depends. Yeah,

Kirstin (17:31):
I'm just kidding.

Dr. Koehler (17:32):
Did you say something? I'm sorry. Were you talking? What was that? Sorry, I can't hear you most of the time.

Kirstin (17:39):
Oh, that's, cuz I interrupted you.

Dr. Koehler (17:41):
No, there's this mosquito buzzing in my ear. I don't know what that was. But anyhow, no, the body lifts. We typically, I'll do a lot of those at the hospital, and because they're a longer surgical procedure, they just tend to be a little bit more involved and they take a longer time. And I just have the ability to just keep them overnight nurse to make sure that they have good pain control, everything's good, and then they usually go home the next day. And occasionally people stay two days. But some of 'em, I'll have some body lifts where the patients are smaller and I'm like, yeah, we can absolutely do that as an outpatient. So again, lots of factors come into whether or not a patient is better served in a hospital setting versus a office setting. And again, we talked about it in a prior podcast about the pros and cons of doing things in the hospital versus in the office. And there's advantages if you have a sicker patient or you need higher level care for whatever reason, then the hospital's the place to be. But surgery centers are nice because we have healthy patients, and if it can be done outpatient, it tends to be more convenient. So pros and cons.

Kirstin (18:43):
As far as recovery for these types of procedures in these patients, would you say it's different for, like you said, people with gastric sleeves, stuff like that? Is there recovery a little bit longer than people who lose massive weight with diet and exercise?

Dr. Koehler (19:00):
No, I think the discomfort is pretty much what it is, and that is very patient dependent. I've had some people at a week, I'm like, you're walking pretty straight and you look like you're not having any pain. And they're like, no, I feel good. And then other people are still struggling at four weeks. So it just depends. But it don't see a difference between those people that lost the weight different ways.

Kirstin (19:23):
Do you recommend compression garments for anything? We know, yes, for tummy tucks, but brachioplasties or lifts, do you ever recommend compression?

Dr. Koehler (19:33):
Yeah, some of the areas are a little harder to get good compression. So a lot of times when we do brachioplasty, which is the upper arm surgery for the first little while, we'll just have people use like an ACE wrap because they can adjust the compression. It does require some help of somebody putting the dressing on, but then they make certain sleeves that once people kind of get through the initial healing, then sometimes you can go to a sleeve, these compression sleeves. But the problem that I found with them is sometimes those sleeves are hard to, it's not a one size for everybody, and sometimes they're too tight for some people and not tight enough for somebody else. So sometimes garments can be tricky. I mean, even with tummy tuck, I mean people, they have to try on different brands and body shapes are different, and it's not one size fits all. So yes, we always recommend compression, but sometimes it can be a little challenging.

Kirstin (20:26):
How at this office do we handle post-op pain?

Dr. Koehler (20:30):
We give you a leather belt and tell you to suck it up buttercup. No.

Kirstin (20:37):
That's not true.

Dr. Koehler (20:38):
I know. I'm kidding. Actually have, prior to surgery, we have something what's called an ERAS protocol, which is an enhanced recovery after surgery. So there's certain medicines that we give prior to surgery to help decrease the amount of narcotic usage that you have because, and we're not anti narcotic, but we do know that actually, although narcotics are helpful, we want you to be alert and mobile and up and moving and being on narcotics for extended periods of time can actually be detrimental. You have other problems like constipation. We definitely give people narcotic medicines, but there's other things that we give both prior to surgery and in surgery to try to help people moving. We give nerve blocks a lot of times for a lot of procedures so that people are more comfortable afterwards. So there's a lot of things that we really do. We don't want people to be in pain, but I do think it's an important thing.

(21:33):
People need to go into this with a realization that there is discomfort. You shouldn't go like, well, I had no idea I was going to have pain, or there will be some, it's surgery, but it's surgery, but it's going to be totally tolerable. You'll be like, okay, this kind of sucks. I'm looking forward to when I feel better again, but it's not going to be writhing around. It's just annoying, and you can't expect to have completely pain-free surgery, I mean minor stuff, yes, but these bigger procedures, it's going to be a few weeks before you feel better.

Kirstin (22:04):
Some of these procedures are going to have pretty big incisions, which you've already mentioned. Are there certain things that people can do to care for those incisions versus like a breast augmentation scar is going to be this big, but a tummy tuck is hip to hip or brachioplasty or thy lift. They're pretty big incisions. So are there things that people should do at home to take care of those?

Dr. Koehler (22:24):
Yeah, we usually go over it in pretty good detail postoperatively, but for the first little while, all you really want to do is just keep antibiotic ointment on there. We have recommendations for scar creams that we like and some that we are not fans of, but you don't want to start scar cream too soon. You got to make sure your incision is healed well enough to then start the scar cream. So that's usually two or three weeks out from surgery. Then you can start these scar creams or you can do silicone sheeting or there's different things, and then whatever scar regimen that you're going to use, we generally like people to do that for three months to maximize the results of that. And sometimes if we have people that early on, let's say it's four, six weeks out, we notice that they're having some thickening of their scars.

(23:12):
There's injections that I can do to help with that. And then we obviously have office procedures that I wouldn't say that need to be done routinely for people, but certainly are available for people who are concerned about their scars. We can do microneedling. We have different lasers that we can use. So we have options. And I always tell people, there is definitely things we can do to maximize the appearance of the scars, but we still are not at the point where it's scarless surgery. You still will have, hopefully, it's a nice fine line, and it takes, even in the best situations, it takes sometimes a year or more for that scar to mature and look as good as it's going to be.

Kirstin (23:49):
Sometimes. I think you're in my brain. That was going to be my next talking point, is the scars and what we can do for the scars. But, why don't you just do my job for me too.

Dr. Koehler (23:58):
I feel like I do. <laugh>

Kirstin (24:03):
<laugh> Bye.

Dr. Koehler (24:03):
Kidding.

Kirstin (24:05):
I just joking. Okay. Well, gosh, I don't know. Well, also, we talked a little bit about insurance possibly covering some skin removal surgeries. If insurance or if you can't get insurance to cover your surgery, is there financing available for people that need multiple surgeries or many huge items?

Dr. Koehler (24:26):
Yeah. Yeah. There's definitely ways. There's companies that we work with to help people finance these things. And again, sometimes we do it in stages. Like I have some of my weight loss patients that they've been patients of mine for several years. We will start off, we'll do their tummy, and then next year maybe we're going to do something else. And we're not trying to fix everything overnight. I mean, yes, it would be nice, but there's a recovery that goes along with the surgery and sometimes people don't have the time off, and then there's the expense. So there's a lot of factors come into play, but we just kind work our way through and get people where they want to be.

Kirstin (25:00):
People call it a journey for a reason.

Dr. Koehler (25:01):
Yes.

Kirstin (25:03):
Okay.

Dr. Koehler (25:03):
Life is a highway.

Kirstin (25:06):
God, please don't sing anymore.

Dr. Koehler (25:08):
I won't do it.

Kirstin (25:11):
Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabama the Beautiful podcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (25:24):
You're welcome. Thank you.

Announcer (25:27):
Got a question for Dr. Koehler? Leave us a voicemail at Alabama the Beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, apple Podcast, Spotify, or wherever you'd like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis. THE AXIS.io.