Two consultations back to back on the same afternoon recently, similar age, a similar amount of loose skin across the abdomen and the arms. One had come from a gastric sleeve. The other had come from a GLP-1. I gave them different answers about when I would take them to the operating room, and the second one wanted to know why.
That question would not have existed a few years ago. For most of my career the phrase “massive weight loss patient” meant bariatric and nothing else: Roux-en-Y or a gastric sleeve, a year to eighteen months of steady loss, a plateau, a six month wait, then surgery. That sequence got standardized over about two decades, and it has held up well.
The GLP-1s have handed us a second population that does not slot into it cleanly, and I am not convinced the field has caught up.
What Deflation Does, Whatever the Route
The mechanism does not care how the weight came off. There is a rapid amount of weight loss, the loss of volume deflates skin that was previously stretched out, and that skin ultimately sags and creates contour irregularities.
Where it shows up is what patients are unprepared for. Everyone anticipates the abdomen. Far fewer anticipate that the loss in volume also creates breast ptosis, in men as well as women, and buttock ptosis, or that it turns up in the arms, the inner thighs, and the outer thighs in anyone prone to saddlebags.
Where the Two Groups Diverge
Timing is the real split. GLP-1 weight loss usually happens over three to nine months, sometimes a year, and those patients seem to plateau a little quicker and to be ready a little faster after they plateau, usually about three months. My post-bariatric patients wait six.
I want to be careful about how hard I state that three month figure. It is my current practice, not a guideline. GLP-1s have been around a lot less time than bariatric surgeries have, so the gold standard and timing of body contouring surgery for them is yet to be defined, and anybody handing you a firm rule right now is quoting themselves.
If I had to explain the divergence, I would point at magnitude. Bariatric patients still seem to have a greater amount of weight loss compared to GLP-1s, and that may be one of the differentiating factors. More total loss means more skin and more nutritional disruption, which happens to be exactly where the complication risk lives.
Where the Risk Actually Lives
Here is the part I think gets underdiscussed at meetings, because it is less photogenic than a before and after.
Post-bariatric patients are still at higher risk for wound complications than GLP-1 patients. This has been seen in recent studies, and it is not surprising. Bariatric patients do have more nutritional deficiencies, and they often have a much higher percentage of body weight loss.
So the preoperative workup is not a formality. We look at protein levels and protein intake before the surgery. We look at hemoglobin, to make sure the patient is not anemic. For these cases we are excising a lot of tissue, so there is a larger degree of blood loss, which usually requires a Cell Saver device to auto-transfuse the patient’s own blood loss, as well as blood transfusions.
A surgeon who is not thinking about protein and hemoglobin in this population before booking the room is going to meet those numbers later, at the incision, on day nine.
The Operation Is Bigger Than People Say
The gold standard is usually an abdominal procedure, a tummy tuck. But more often than not, because of the massive weight loss, it has to be extended circumferentially, so we can lift the buttock and the lateral thigh, reduce the lower back, and fix the abdomen at the same time. Add a monsplasty. Add a breast procedure, usually a full lift with an anchor-type incision, or a gynecomastia reduction in men. Then frequently a brachioplasty, a medial thigh lift, and excision of back rolls or lateral chest rolls.
Doing all of it in one sitting usually entails an overnight stay and a possible transfusion. Splitting it, in my hands, works best as upper body then lower body. Facial work, facelifts and neck lifts, gets staged in along the way.
Recovery scales accordingly, and this is where I see the most unrealistic expectations. A tummy tuck alone usually needs about two weeks. Combine procedures and we usually need at least three weeks to return to normal activity, and it can be six to eight weeks before any exercise. Patients budget for the tummy tuck number. Their bodies bill them for the combined one.
No, the Device Will Not Save You Here
I am one of the highest-volume Renuvion J-Plasma users in the world, so I am not the guy talking down energy devices. I will still say this without qualification: once the skin has been stretched out to a certain degree, it loses its elasticity and really does not react to radiofrequency energy the way healthy skin would. When the laxity is significant, the only option at that point is excisional.
That does not mean we may not have different tools in the future. As of this writing, that is the recommendation, and selling a massive weight loss patient a device package instead of an operation is selling them a disappointment on a three month delay.
Scars, and the Conversation Nobody Wants to Have
Most of these scars can be hidden by normal clothing. The circumferential body lift hides under swimwear or underwear. Some do not hide well: the arm lift is the obvious one, and so is a vertical abdominal scar, the fleur-de-lis, or an extended medial thigh lift with its vertical scar running from the groin to the knee.
Oftentimes patients are willing to have these scars because of the amount of excess skin in those areas, and ultimately they will feel better in clothing than not doing anything at all.
That is the trade, stated out loud. Balancing pros versus cons, benefits versus risks and scars. It requires a full consultation with a conversation about expectations, and if a surgeon has not had that conversation with you, you have not had a consultation. You have had a sales meeting.
Where I Am Coming From
Double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, Mayo Clinic fellowship-trained, Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, and a Castle Connolly Top Doctor for thirteen consecutive years. I have written the full patient-facing version of this over on Agullo Plastic Surgery, with the timelines laid out in a table.
Ready to Talk?
If you have lost the weight, whether by surgery or by prescription, and you want a straight answer about when you are ready, come in with your labs.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com/appointments. #StayBeautiful
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
Cross-links
- Full patient guide on agulloplasticsurgery.com: “When Are You Ready for Body Contouring After Massive Weight Loss?” (link once live)
- Practice version on swplasticsurgery.com: “Planning Body Contouring After Major Weight Loss at Southwest Plastic Surgery” (link once live)