Three men in one afternoon. One lost 70 pounds with diet and exercise and no medication. One lost 74 on a GLP-1 and has kept it off for four months since stopping. One lost 80 over two years and trains five or six days a week. Different roads, same exam: the fat is gone, the skin is still there. I am publishing the exchanges nearly as they happened, identifiers removed.
The first man: tummy and neck
Me: “Have you lost weight? How much have you lost?”
Him: Seventy.
Me: “Oh, great. Congratulations. Let me have you stand. So there’s a lot of excess skin there. To completely get rid of this loose skin, it would be a tummy tuck. The incision is low, so you can hide it with shorts or boxers or swimsuit. I do have to go past where this fold ends to get rid of it completely. I would actually pretty much be able to get rid of everything from here down, and then use this skin, and we just pull it down. I also take some of the fat off of the mons and lift it up, so that also helps make everything nice and smooth all the way down.”
Me: “I suspect that because you were a lot heavier, there is maybe some separation in the muscles, so I actually repair that, so it makes everything tighter as well. And we combine that with liposuction, especially here on the waistline and here on the lower back, the upper back, and the sides. If we only did liposuction, I think we would get rid of the filling, but then everything would sag more.”
Him: And do you use a mesh?
Me: “We don’t really need to. I use it when there’s a hernia or like severe diastasis. If we can avoid putting something that we don’t need in the body, it’s better. Just with the sutures, we get great results.”
Me: “There’s still some visceral fat that, of course, is always pushing out a little bit. So that limits how much I can tighten everything, but I think you’re ready for the surgery, because there’s not that huge amount of fat anymore on the outside. It’s just mostly a lot of loose skin. I have a good handful, so it’s abundant. It’s enough that with liposuction, it’s not going to flatten out. We really need to cut it out.”
His neck
Me: “You have a combination of the fatty tissue that’s on the outside, which is not that much, but there is a fatty tissue that’s a little bit deeper inside, below the muscle itself. And of course, there’s a little bit of the gland here that actually fills that in as well. So to do this, I make an incision that goes right here, and then we do have to make one here on the back of the ear. I may have to go a little bit in front of the ear, because when I do that, it bunches up a little here, so I may have to just tuck a little bit here so that it doesn’t look funny. Once it heals, you really wouldn’t see it.”
Him: Do you recommend doing it at the same time, or doing it later?
Me: “The combination is something we could do together. The big advantage is just having that one recovery versus having to take time twice. The face part really doesn’t add anything to the recovery, because there’s really no pain in this surgery. It’s mostly just waiting for everything to heal and the swelling to go down. The tummy takes a couple of weeks to get back to normal, easy going activity, so by that time, your neck would be pretty much looking really good.”
Him: I work in a very public place, and everybody’s looking at me.
Me: “In two weeks, you would probably be pretty much healed. If you have something really important, I’d say six weeks is when it’s looking its best. But the same thing as in the tummy, if we just did lipo here, you’re not gonna see it because of the loose skin. The face and neck is the first thing. We’re seeing a lot more since Ozempic started. I’m almost doing three or four every week now.”
Him: As far as if you happen to find a hernia?
Me: “If I find it, I’ll fix it. I’m a board certified general surgeon too, so I have a lot of experience with hernias. If I find it beforehand, I’ll charge you a little bit. If I find it while I’m doing it, I just take care of it. There’s nothing additional.”
Him: The hard part is finding someone to help. I’d have to find somebody.
Me: “We do offer an overnight stay for people that don’t have anybody to transport them. We also have a transportation service. Eighty percent of my patients are from out of town, so we know how to deal with all these special situations. My nurse does do a visit at your house the day after, for the first shower and going over all the instructions. You can extend that, and we also have a service where somebody can actually be with you twenty-four hours a day for as long as you want.”
Him: Do you see a lot of male patients?
Me: “Yeah. And especially now with the weight loss, it’s becoming more and more common. You did it by yourself? That’s the hard way. If you did it the hard way, it means that you can really keep it off.”
The second man: tummy and arms
Me: “So you lost 80 pounds? That’s great. Over two years? And are you pretty stable now? Good. So for the abdomen, I do see that you have the loose skin here that kind of flaps over, and of course the fullness here. You don’t have a lot of fat on the outside, so a lot of the bulging here in the abdomen is some of the fat that’s on the inside pushing out, the visceral fat. Plus, when you were heavier, of course, you stretched out the muscles, so it kind of blows up a little bit easier.”
Me: “When you lay down, does it go pretty flat? Let’s take a look, because laying down gives us an idea of how flat we can get it. Yeah, so that looks a lot better. And sit up for me. You see the diastasis here, that’s the muscle separation. So when we put that together, your stomach will look like this when you’re standing.”
Me: “So the arms, you’ve lost the elasticity here. There is a little bit of fat, but nothing major. It’s mostly just loose skin. So we would have to do an incision that goes right here, and with that I can cut all that out and really make it tight so it’s uniform all the way and nothing’s dangling. It hides on the inner part of the arm.”
Me: “So this surgery takes right about five hours. It’s general anesthesia. The tummy takes about two weeks to get back to normal, easy going activity, driving, things like that. And then six weeks where you wouldn’t have any more limitations. The arms really don’t add much to the recovery. The tummy is the main thing. You would have a drain in the tummy area, and that one’s gonna stay between seven and fourteen days. Everybody’s a little different, but what we wanna do is for all that fluid to come out so it doesn’t pool behind your skin, because that can create irregularities or other problems.”
Him: So that two weeks, that’s like no work for two weeks, right?
Me: “You may be able to start doing some at home a little bit earlier, maybe like on day seven or nine. I think the first week’s a little tough, because more than anything, you’re going to feel fatigued, because your body’s working overtime trying to heal everything. It does take about two weeks to feel comfortable driving.”
Him: What about the drain? It’s two weeks with the drain in.
Me: “So the drain is a little tube, and it has a little bulb, and it’s just suctioning fluid into the bulb. Every day, at the beginning it’s gonna be more than once a day, you just empty it into a cup to read the measurement, write it down, flush it down the toilet, and then close the drain and you keep going. You can shower and everything. We’ll give you a lanyard where you can clip the drain to so it doesn’t get stuck on anything.”
The third man: tummy and chest
Him: I was at two ninety-eight. I’m at two twenty-four.
Me: “Did you do any of the GLPs?”
Him: Yes. I stopped it like four months ago already.
Me: “And you’ve been able to maintain? Good. Excellent. So you have a lot of skin here hanging. The incision’s gonna be below that fold, right here, and it’s gonna go to where the fold ends. With that, I can remove pretty much all the skin from here down. Then I use this skin, and that’s the one I’m gonna pull all the way down. And then we can also do liposuction on the mons, remove the fat pads and pick it up. That also helps to show the penis a little bit more, but also so that everything’s nice and flat all the way down.”
Him: And it was like this area too, like here.
Me: “Would you wanna do some on your chest too, or just the sides? So here, what I would do is just liposuction with the skin tightening to get it tight. When I do liposuction here, sometimes we still have this gland here. So through that little same incision, I put in an arthroscopic shaver. I actually take that gland off so that everything is nice and flat, and then we see your muscle instead of any fullness.”
Me: “We can do all that together. It takes about five hours. It’s general anesthesia. We’ll keep you overnight. You go home the next day. If we do the chest area, we also give you like a vest. You will have a drain in the chest and the tummy, and those usually come out in seven to fourteen days. Then with any liposuction, I really recommend doing the lymphatic drainage massages. It just helps get the swelling down faster, and also gets you up and going a lot faster as well.”
Me: “If you continue to lose weight, you may see a little loose skin again. You might need like a touch-up. More often than not, no, because I’m really gonna pull on the skin. I’d like you to be pretty close to where you wanna be for the surgery. If you do that, then your results are pretty much permanent.”
My exam notes that afternoon, in order: exuberant pannus with diastasis and submandibular gland show; excess skin with a substantial amount of visceral fat, much flatter lying down, six to seven centimeters of rectus diastasis, no palpable hernias; pannus, rectus diastasis, excess tissue of the chest with fullness and ptosis.
A man who has lost 70 or 80 pounds has already done the hard part. What is left is a skin problem, and skin problems are surgical. Cut out what will not shrink, repair the muscle, lipo the edges, and get him back to the gym in six weeks.
I am a double board-certified plastic surgeon, a Mayo Clinic fellowship alum, and I teach plastic surgery as a Clinical Associate Professor at Texas Tech University Health Sciences Center.
Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.
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