After losing the weight, patients want to shed skin

KANSAS CITY, Mo. — Teresa Gretencord's fat all but melted off.

All her life, the 45-year-old nurse had been obese. Six feet tall, Gretencord weighed 350 pounds on the day, in October 2004, she opted to shrink her stomach to the size of a thumb with a surgical gastric bypass.

At 28, Laura Brown did the same. She was 5 feet 7 and weighed 270.

Both women watched ecstatically as 165 pounds for Gretencord and 120 pounds for Brown fell away within a year. They were likewise mortified at what they saw in the mirror: fold upon fold of sagging skin.

"With my clothes on, I looked fine," said Brown, now a 30-year-old triathlete. "But if I took my pants off, I looked like a shar-pei."

More than 170,000 morbidly obese Americans had major weight-loss surgery in 2005, up more than 130,000 in five years. But lost in the hype over miraculous body makeovers is the fact that gastric bypass is often only the beginning.

With the precipitous increase in what's known as bariatric surgeries has come an equally large increase in what, for many, are the extensive and expensive second, third and, in rare cases, fourth body-contouring surgeries necessary to bring the body back into shape.

Process can be pricey

The price, which insurance rarely covers, typically ranges from $15,000 to $25,000. It can reach as high as $50,000.

"With most patients you're talking two, three, four stages of surgery, depending on what they need," said Dallas plastic surgeon Jeff Kenkel, chairman of the post-bariatric surgery task force for the American Society of Plastic Surgeons. "You're probably talking about a four- to five-year process from having the bariatric surgery, losing the weight over one or two years, and then completing the body contouring ... which can be another couple of years."

Body contouring involves cutting away sheaves of loose skin to perform any number of "lifts": face, thighs, breasts, upper arms, neck, buttocks, stomach, lower-body or even whole-body lifts.

Body-contouring procedures nationally have increased 77 percent between 2000 and 2004, the most recent year for which statistics are available. The American Society of Plastic Surgeons estimates that the 106,000 body-contouring procedures done in 2004 are a tiny number compared with now.

The trend, active nearly everywhere, is driven almost exclusively by massive weight-loss surgeries. Of the 106,000 body-contouring surgeries in 2004, close to 56,000 were because of massive weight loss alone. Between 2003 and 2004, upper-arm lifts increased 57 percent. Thigh lifts were up 61 percent.

"I'm seeing several new patients every week who have lost anywhere from 75 to 250 pounds," said plastic surgeon Richard Korentager, of Shawnee Mission, Kan.

Jeffrey Dillow, an Overland Park, Kansas, plastic surgeon, said body contouring surgeries in his practice have increased 50 percent in four years.

"If you look long term, 10 years out, we won't have enough plastic surgeons to treat all of these patients," Kenkel said.

To be sure, patients contemplating massive weight-loss surgery are not left unawares. For most severely obese people, the bariatric surgery is not cosmetic, it's lifesaving. In general, any discussion of massive weight-loss surgery typically includes pre- and post-psychological counseling, nutritional counseling and discussion of future body contouring.

"I'm very upfront about it," said physician Stan Hoehn, a surgeon at the Bariatric Center of Kansas City. "It is a matter of fact: If you lose 150 pounds from an elastic organ such as skin, you're going to have saggy skin."

Some patients' skin hangs so loose, Dillow said, it must be rolled up and placed in their clothes.

"You have skin hanging around everywhere," said Gretencord, who underwent body contouring in May. "You don't want to wear short-sleeved shirts, or shorts. Even though you have lost all this weight, you feel very fat."

Trading scars for shape

Massive weight-loss surgery comes in three types: restrictive, malabsorptive or a combination. Restrictive reduces the size of the stomach, and thus food intake, using sutures or an inflatable silicone ring (Lap-Band). Malabsorptive entails rearranging the intestines to reduce absorption of calories.

Each requires major surgery and has risks, such as infections and clots.

Body contouring is just as major.

"It's very involved," Dillow said. "One operation can take six to eight hours."

For some patients whose hanging skin causes severe rashes, ulcers or infections, insurance sometimes pays part. As with all major surgeries, the procedure involves just as many potentially serious risks.

"Mine was a seven-hour procedure," Gretencord said of her lower-body lift done by Dillow. "He actually took about 10 pounds of skin. Then he did extensive liposuction down in my legs and back and stomach and thighs. I went from a size 14 to a size 8/10" from the surgery.

After surgery, patients often return home with drainage tubes, wear elastic garments and must limit their activity for weeks, requiring vacation or short-term disability time.

"For a while, I went home with four drains in me and a pain pump," said Brown who had her lower-body lift earlier this year.

Additional smaller surgeries, such as breast or arm lifts, are often needed over several years.

"They are going to have scars," Kenkel said. "You are trading scars for body shape."

If rising numbers are a guide, it's a trade-off many feel is worth it.

"You have to have realistic expectations on what your body is going to look like," Gretencord said. "You're going to have surgical scars. You're not going to look like a model. You have to know what you want when you go in."

Brown's take: "I did seven triathlons last year, and I hadn't been on a bike in 15 years. I still sometimes think of myself as the fat girl. But when I look in the mirror and see who's looking back, I'm startled. Pleased, quite pleased, but startled."