When there is skin left over after losing weight

This consultation comes up more and more often, and almost always with the same sentence: "I lost thirty kilos and now there is skin left over." It makes no difference whether it was bariatric surgery, a medical treatment or years of persistence; the point of arrival is the same.

And the first thing to say is that it is not a matter of waiting longer or training harder. Skin stretched over years has lost its ability to retract: it hangs like an apron over the abdomen, folds at the flanks, drops at the lower back and empties the buttocks. That does not improve with time.

What excess skin does every day

It is worth naming, because it is usually suffered in silence and because it explains why this operation is not a whim:

• Irritation and fungal infections under the folds, coming back every summer however often they are treated.
• Difficulty keeping clean and finding clothes that do not show it.
• Limits on exercise, in exactly the person who has just made the effort to lose weight.
• A body that does not match the achievement. Many patients describe still not recognising themselves after the whole journey.

The timetable: twelve months of stable weight

This is the condition people most try to negotiate and the one with least room. You have to wait for the weight to settle for at least twelve months.

The reason is simple: operate while the weight is still coming down and the skin will be left over again, and it has to be repeated. Operate and then put weight back on and the result is undone. The plateau is not red tape; it is what makes an operation of this size worth going through once.

The part almost nobody expects: nutrition

After bariatric surgery it is common to be carrying deficits of protein, iron, vitamin B12 or vitamin D without knowing it. And a wound of this length needs protein to close.

Operating on someone with empty stores is close to guaranteeing that the wounds will open. That is why the bloods are reviewed first and, if there are deficits, they are corrected and surgery waits.

It is the step that most often delays the date and the one that prevents most complications.

What a body lift is, put plainly

It removes the excess skin around the whole trunk — abdomen, flanks, lower back and buttocks — with a scar that goes round the waist like a belt. The change is among the most dramatic plastic surgery offers, and many patients describe it as the end of the weight-loss process.

It is also, without argument, the largest operation we perform: four to six hours in theatre, two or three nights in hospital and between thirty and forty-five days before normal life.

And it carries a medical risk unlike that of a liposuction

It has to be said in plain words: it is the cosmetic operation with the highest medical risk. Deep vein thrombosis and pulmonary embolism, bleeding needing transfusion, respiratory complications and everything that comes with a long operating time.

That is why the preparation beforehand is so demanding, why smoking here is a practical contraindication rather than a recommendation, and why the right answer is sometimes to split it into two stages even though that means recovering twice.

What the recovery is really like

• Days 1 to 10. Hospital, drains, a permanent compression garment and help with almost everything. You walk from the first day, a little and often: that is what prevents thrombosis.
• Weeks 2 to 4. At home, with gradually increasing independence and wound care. Close watch on the wounds, especially at the lower back.
• Weeks 5 to 8. Back to office work at around one month to six weeks. Garment all day.
• Months 3 to 12. Gradual exercise once cleared. The final contour appears at around six months and the scars mature over the year.

You need someone at home for the first weeks. That is not a logistical detail: without support, this recovery does not hold together.

What is not promised

You are not promised a body without marks. Hanging skin is traded for long scars, and that is the nature of the procedure: anyone unwilling to make that trade should not have the operation, and that is a perfectly reasonable decision.

Seroma is very common, the wounds can open at some point and a proportion of patients need a touch-up operation. Nor is everything solved at once: arms and thighs, if there is excess there too, are separate operations with their own timetable.

All that said, it is one of the most satisfying operations there is, and the reason is the one patients give themselves: they do not feel they changed something about themselves, but that they finally finished what they started.