Loose skin after weight loss: why it happens and how it is treated

Because the skin has been stretched for a long time and has lost elasticity. With excess weight, the dermis, that is, the layer of the skin that gives it firmness, stretches to cover more volume, and the collagen and elastin fibers gradually become damaged. When the fat is lost the contents go, but the wrapping stays practically the same size.

How much the skin recovers depends on each person. What matters is how much weight was lost and how fast, how many years the excess weight was there, age, genetics, sun and smoking. Losing muscle along with fat also counts for a lot, because the skin is left without the support that kept it taut. And in women there are pregnancies, which stretch the skin of the abdomen and often separate the rectus muscles, what we call abdominal diastasis.

Is it normal to be left with hanging skin if you lose 40 kilos?

Yes, it is the normal thing. With losses of that size the skin almost never retracts completely, and it has nothing to do with having done it well or badly. We see it just the same in patients who have lost weight with diet and exercise as in patients who have had bariatric surgery or are being treated with drugs for weight loss. In these two cases the weight loss is usually faster, and the skin has less time to adapt.

The areas that show it most are the abdomen, where an apron of skin sometimes forms and hangs over the pubis, the flanks and lower back, the inner arms and thighs, the breasts and the buttocks. And it is not only an aesthetic matter. Chafing, irritation and sometimes infections appear in the folds, and it is hard to find clothes that fit well.

How do I know if my case needs surgery?

The first thing we look at is whether there is laxity or excess skin. Laxity is skin with less tone, but with none to spare. Excess is skin that hangs and that the patient can pinch with her hand to form a fold.

With mild laxity and no folds, there is room to improve without the operating room. When a small fold appears, for example below the navel, sometimes medical treatments are enough and sometimes a smaller surgery is the better option. If there is an apron or folds that do not go away, then we are talking about surgery. In the assessment we also look at the abdominal muscles, the fat that remains and the quality of the skin, because all of that changes the technique we are going to choose.

What can be done without surgery?

With mild laxity, strength training and aesthetic medicine treatments that stimulate collagen both work. Building muscle partly fills the space the fat left behind and improves the contour, especially in the arms, buttocks and legs. Eating enough protein, not losing weight all at once and not smoking all help.

In aesthetic medicine we can use body radiofrequency or biostimulators such as polylactic acid, and if there are stretch marks, treatments to fade stretch marks. We have to be honest about this. They improve the quality and firmness of the skin, but they do not remove excess skin. No cream, no device and no abdominal routine is going to remove an abdominal apron, and promising it would be misleading the patient.

Which surgery removes excess skin after weight loss?

It depends on where the excess is. On the abdomen we do an abdominoplasty or a lipoabdominoplasty, when there is excess skin all around the trunk a body lift, and on the arms, thighs or breasts, their specific lifts.

What is a lipoabdominoplasty?

It is an abdominoplasty combined with liposuction, and what the patient notices is a flat abdomen, without the fold of skin and with a more defined waist. In the abdominoplasty we remove the excess skin and fat from the lower abdomen, tighten the skin that remains and, when needed, repair the abdominal wall, that is, we stitch together the rectus muscles that had separated. If we also remove fat from the flanks and the upper abdomen with liposuction, we call it a lipoabdominoplasty. In women who have had children it is often combined with breast surgery, which is known as a mommy makeover.

The scar sits low, at the level of the underwear. It is a long scar, that has to be said from the start, and it fades over the months.

Case 1: 30 kilos lost and several pregnancies

This is a patient who lost about 30 kilos after several years of being overweight, and who had also had several pregnancies. We performed a lipoabdominoplasty with repair of the abdominal wall. She had her surgery several years ago and is very happy, with a very comfortable result. The fact that it has lasted so long has to do with her having kept her weight stable and with the fact that, as well as removing skin, we rebuilt the muscle wall that supports the abdomen.

You do not need to have lost a lot of weight to have excess skin. This patient is younger and, after two births, had a significant diastasis and excess skin on the abdomen, with little fat. We also performed a lipoabdominoplasty with a major repair of the whole abdominal wall, and removed the excess skin and the small amount of fat she had. Today she is very happy.

When is a body lift needed?

When there is excess skin all around the trunk and not just at the front. After very large losses, especially after bariatric surgery, the skin also drops on the flanks, the lower back and the buttocks, and an abdominoplasty falls short because it only treats the front.

The body lift, also called a lower body lift or circumferential dermolipectomy, that is, a removal of skin around the whole waistline, makes it possible to remove that excess at the front, at the sides and at the back, and at the same time lift the buttocks and the upper thighs. The scar goes around the waist at the level of the underwear. It is a more extensive surgery than an abdominoplasty, and before recommending it we carefully assess the patient's general condition. In people who have lost a lot of weight it is usually the one that gives the most complete change. On the body lift page we explain who it is indicated for and what the procedure is like.

What if there is excess skin on the arms, thighs or breasts?

Each area has its own surgery. The skin that hangs on the inner arm is corrected with an arm lift, or brachioplasty, that of the inner thigh with a thigh lift, and breasts that have emptied and dropped with a mastopexy, with or without an implant. We do not usually do everything in a single operation. We plan it in stages, a few months apart, so that each recovery is easier to get through.