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Terry Streetman (Host): Hello, listeners. Thank you for tuning in to the Well Within Reach podcast, brought to you by Riverside Healthcare. I'm your host, Terry Streetman. And joining me today is Dr. Alec Fisher, a plastic surgeon here at Riverside, and he's going to talk about life after weight loss and considerations patients might have about excess skin. Thanks for joining us.

Dr. Alec Fisher : Happy to be here.

Host: All right. Well, we're glad to have you back, but could you just give our listeners a quick reminder of your role and your background?

Dr. Alec Fisher : Yep. I'm Dr. Alec Fisher. I'm a plastic and reconstructive surgeon for the area. I've been with Riverside over a year, and I do a wide variety of different surgical services, anywhere from microsurgery to cosmetic surgery to what we're talking about today, body contouring after massive weight loss.

Host: Okay. Thanks so much. And we will jump right into it. Kind of a basic question. Why does excess skin develop after weight loss, and why doesn't it shrink back to fit?

Dr. Alec Fisher : So, your skin has something in it called elastin. And the elastin, you can think of it as a rubber band thatkind of keeps your skin tight to your body. After gaining a lot of weight, that elastin, those molecules get stretched out to a point where they can't become as stretchy and pull back the same way. So, we've all blown up a balloon. If you overfill the balloon and then let the air out, the balloon doesn't have the same stiffness as it once did. I know that's a bit of a crude analogy, but a very similar thing happens with the skin on a cellular level. So, the skin then drapes back to the body after losing weight in a less than ideal manner, and it doesn't have the same stretchiness it once did.

Host: Okay. And do we see this loose skin like this, is it more common after surgical weight loss compared to diet, exercise, or medication, or kind of the same?

Dr. Alec Fisher : Yeah, it doesn't really matter. What matters mostly is how much the skin was stretched at its maximum. And then, interestingly, there's some studies that say the skin is actually looser if you lose the weight rapidly. So, this is not to say, you know, I think you should lose weight at a slow rate, because this happens if somebody's really heavy and then loses a lot of weight. The elastin's never going to be the same regardless of how fast you lose it. But it does seem that the skin hangs a little bit lower or looser if the weight is shed in a very quick manner versus over a course of years. Regardless, when people are over, you know, a very heavy weight or over an ideal body weight, the skin is put on stretch. And with aging too, the elastin goes down. So, it's a combination. With aging and with dropping weight, that skin just hangs really loosely, and it can be really bothersome for patients.

Host: Okay. And what areas of the body then would you say are most frequently affected by and treated for this excess skin?

Dr. Alec Fisher : I think my patients would tell you everywhere, which is sad. But the most common areas that I treat are the abdomen, the breast or the chest for males, the back, particularly the lower and upper back. I think both those areas need to be addressed. The thighs are really commonly affected, and then the upper arms are really affected.

And then, an interesting area, which I do a lot of work with too, is the face, because the neck and the jawline and the lower half of the face never drape the same. People call this, like, jowling or a turkey neck, kind of crude names for it, but that is an area that's significantly affected by weight loss too.

Host: Okay. So if someone has gone through this process of gaining a lot of weight, losing a lot of weight, they're noticing some of this excess skin, at what point should they consider talking with a plastic surgeon like you about this?

Dr. Alec Fisher : Yeah. So, that's a moving target. These surgeries are, for me and for the patient, one and done. So, you want to time these surgeries at the right point for the patient. And I kind of stress this in the office, which is you want to be at a goal weight, meaning, if you lose an additional 20 pounds after we do the surgery, it can affect your results. So, you ideally want to do the surgery when your weight's stable, and everybody has a different definition of this. I think weight stability is where you're at your goal weight, you can maintain your weight with your regiment, whatever that is, whether it's lifestyle changes, medications, or exercise, and you're at that weight for six months, and you know that you can hold it after surgery. Also, unfortunately, if you were to rebound and gain weight, that would affect the results too. So, we want to make sure that this weight is something that can be held for a lifetime.

The other thing that, you know, you always want to consider with surgery is you want to do the surgery when you can afford the surgery in a recovery standpoint. All surgeries have a, six-week-ish recovery to them, where you may not be able to work, and you may not be able to take care of your dependents if you have kids. So, you want to do this surgery at the right time, both in a social setting where you can have support, have help for your recovery, where you don't have a lot of obligations, and you don't feel stressed out by life, and you can focus on yourself and recover. And additionally, you're at a stable weight that's not going to change after these operations.

Host: Okay. So, yeah, and I think that really shows us the importance of building those lifelong healthy habits that we talk about a lot across the board in medicine so you can maintain that. So, that's good for folks to know.

Before we move on with this conversation, we will pause to discuss the importance of primary care.

At Riverside, our primary care providers are right here in your community, offering personalized care for you and your family, close to home and connected to the specialists and services you may need.

Having a primary care provider means having someone who knows you, listens to you, and helps you stay well through every stage of life. From annual checkups and preventative screenings to managing everyday concerns when they pop up, because remarkable care should never be out of reach. Remarkable care right where you live.

To find a primary care provider who's right for you and your family, visit myrhc.net/acceptingnew.

Okay. We'll keep going on this conversation. So, you mentioned some of the recovery elements, but what are the risks and benefits that patients should understand when they consider this kind of surgery?

Dr. Alec Fisher : All these surgeries are major surgery. There's no way around it. You know, we're trading the excess skin for scars, and we have to cut off that skin, and that can cause changes to the body. You can expect a lot of swelling. With any surgery, there's a risk of infection, bleeding, or fluid buildup.

For these types of surgeries, infection and bleeding is very low risk. The higher risk and more common thing we see is what's called a seroma or fluid being built up in the space where we move the skin around. It's not the worst thing in the world, but it can be quite annoying for patients, and that's a common complication.

And then, there's always delays in wound healing. Surgery's never free, but my job is to make those complications as minimal as possible. I can safely say we have a low complication risk in our office and with our team, but it's real surgery, and I don't minimize that.

Host: Yeah. Well, I appreciate that, because I think people need to be aware of that kind of thing. And you kind of touched on this, but speaking of the scars, what should patients expect from scars, and how do you minimize them, and how do your particular skills as a plastic and reconstructive surgeon help with that?

Dr. Alec Fisher : Yeah. I try and put the scars in places where they're not going to be unsightly or bothersome to the patient, but there is scarring. And my job is to make the scars as minimal and as least unsightly as possible, which I can do as a plastic surgeon. But there's no way around it. I can't remove a lot of skin without placing a scar somewhere.

So for the belly, I try and place the scar down low in the underwear line or bikini line so that it's hidden when you're wearing a bathing suit or clothing. For the chest in males or the breasts in females. That scar is going to be hidden within a bra or a bikini line for females. And for males, it will definitely be covered by any type of shirt. The arms are tricky. I try and place the scar for that one kind of inside the inner groove of the arm. So that way, when the arms are down, you can't see the scar because that scar has to run from the elbow to the armpit.

And then, same thing with the legs. I try and hide the scar in the inner aspect of the thigh. But these scars are as good as can be made with all my plastic surgery techniques and using good tissue handling and using low-profile sutures. But there's no way around it. If a patient wants skin removed, they have to have a scar somewhere.

Host: Sure. Well, we appreciate that you can use your experience and your skills and techniques to make that as good of a process as possible. So, we talked earlier, you know, when should a patient consider talking to a plastic surgeon, but how do they get started? Do you need a referral? Can you go straight to you? How does this work?

Dr. Alec Fisher : Yeah. Usually, patients get a referral from their primary care provider. Typically, the patients that get insurance coverage for treatment are the ones who get rashes under the folds of their skin or have skin irritation or issues. So, a common way is patients will see their provider about these rashes or discuss that the skin is bothering them, and then the primary care provider usually refers them to me. Patients can call our office too and make an appointment and see us and talk about this.

And then, when they meet me, we talk about where your weight was, where it is, what your goal is, and we sort of figure out what parts of the body are bothering you the most, and then figure out when and where you're going to be at your goal weight to figure out timing for surgery. We submit to insurance, we see what they say, we try and get as much covered, because the skin it can cause medical problems for patients. And we have a good track record of getting certain surgeries covered by insurance for patients. So, we can jump in at any point in the process. But my job is to figure out with you when the best time to do the surgery is.

Host: Okay. And you kind of touched on what my next question was going to be, you know, are these covered by insurance? So, it sounds like some of these—for this excess skin that can be covered.

Dr. Alec Fisher : Yeah. It really depends on a patient's insurance company. But a lot of the major insurances cover the abdomen, in some degree the chest, and sometimes the arms and sometimes the legs.

It really just depends on how bad the excess skin is what kind of rashing is going on, and what the insurance carrier covers. So, it is helpful if a patient calls their insurance company and kind of understands what the coverage guidelines are for these, because some insurances feel that these surgeries are cosmetic, and we run into some trouble sometimes getting coverage even though I agree with the patient that it's medically necessary.

I always advocate for the patients as much as I can because I do think that the skin causes a lot of trouble for patients, and removing the skin is a very positive thing for these individuals and kind of gives people a new lease on life in their slimmer, new bodies. So, it's a very rewarding process.

But sometimes insurance does get in the way, I'm not going to lie. So, it's helpful when patients call their insurances, understand the limitations in coverage. And then, we work with the patient to try and get these covered as much as possible.

Host: I'm sure the patients really appreciate your advocacy on that and working with them because it's a confusing process in the best of circumstances.

Dr. Alec Fisher : Yeah. And shout out to my office staff. They are all incredible at working with insurances, working with the patients, and we try and make this as easy of a process as possible for the patients, and we couldn't do it without the whole team approach, and that definitely includes my PA, my office staff, and everyone working with me and with the patient to try and make this a smooth and seamless process.

Host: I feel like that's a common theme in our interviews, is the team that's behind the provider and behind the patient helping out. I think that's a pretty big deal.

Dr. Alec Fisher : Yeah, I think so too. I joke with them and say I have the easy job, which is taking care of the patient, but they're the ones who get everything set up, and they really help make this process easy from start to finish for patients.

Host: Nice. Yeah. All right. We're getting to the end here. So, one of my favorite questions to ask, what is the biggest thing that listeners should take away from this episode?

Dr. Alec Fisher : Skin can be really irritating and bothersome to patients after losing weight. And I think that the extra skin is the scar of prior obesity. And we can trade that for a physical scar. And it's an honor and privilege to do that with patients. But I just want to remind everybody that these are major surgeries. We take them very seriously, and we take good care of patients undergoing these surgeries. And our team is here to work with patients on their weight loss journey andkind of help them cross the finish line in this regard.

Host: All right. Well, if our listeners are interested in learning more about how Riverside's Plastic and Reconstructive Surgery can help deal with some of these issues, help you move on from some of the frustration and the irritation of this issue, and restore or create new confidence, you can visit myrhc.net/plasticsurgery. Thank you so much again for being here, Dr. Fisher.

Dr. Alec Fisher : Thanks for having me. Always a pressure.

Host: Of course. Thank you, listeners, for tuning into the Well Within Reach podcast with our guest, Dr. Alec Fisher, and me, your host, Terry Streetman. Be sure to like and subscribe to Well Within Reach on Apple, Spotify, or wherever you get your podcasts. To learn more about the services of Riverside Healthcare, visit riversidehealthcare.org.