Joey Wahler (Host): It's an important part of the process. We're discussing skin removal after weight loss. Our guest is Dr. Ayesha Punjabi. She's a plastic and reconstructive surgeon. This is Southwest General Health Talk, a podcast from the specialists at Southwest General Health Center. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Ayesha Punjabi, MD: Hi, thank you for having me.

Host: Great to have you aboard. We appreciate the time. Looking forward to this because it seems to me that this is a part of the weight loss process that often gets overlooked, maybe not discussed as much publicly, and perhaps patients of yours don't think about it as much, right? What happens after the weight loss surgery? So, let's jump right in. And for those who've lost a significant amount of weight, what kinds of changes can in fact happen to the skin and that body contour after the fact?

Ayesha Punjabi, MD: The skin is viscoelastic. A viscous material is like Silly Putty. When you stretch it, it just stays stretched. An elastic material is like a spring. When you stretch it, it bounces right back together. The skin is in between those two. And so, with changes in weight, when the skin stretches and then contracts again with weight loss, there is variability in terms of how much the skin will spring back up or tighten back up once the fat beneath it has decreased in volume.

And so, excess skin is a very common presentation after weight loss. And depending on the rate of weight loss, the age of the patient, there are just deposits of extra skin that can be left behind after weight loss. And no amount of working out, further weight loss, anything that people can do can remove that extra skin because this is kind of an intrinsic property of the skin.

Host: Gotcha. And so that being said, at what point should someone start thinking about skin removal surgery? Is there a certain amount of weight loss or a certain period of weight stability that you normally look for?

Ayesha Punjabi, MD: Yeah. So, there's actually a lot in that. The first actually, the most important part, is the weight stability. So, I recommend that patients be within 10 pounds for six months. That's what I consider weight stability, and that's actually the most important thing. In terms of the number, I don't encourage people to get super fixated on chasing a number.

Number one, I always recommend losing weight under the guidance of a specialist in weight loss. I think that's the safest way to lose weight. And number two, patients are losing weight for their health and getting arbitrarily attached to a number is less healthy.

All of that being said, as much as we hate the body mass index, it's not the most precise, I do warn patients above a body mass index of 35, which is a ratio of weight to height, above that body mass index of 35, there are some healing complications of surgery that are a little higher.

The other important thing is comorbidities with the weight. So if someone has poorly controlled diabetes, for example, that's a very major risk for healing complications, and I would recommend getting the diabetes under control before a major elective surgery.

There's actually a lot in that question. And hopefully, I cleared things up more than muddying them with that answer.

Host: Absolutely. Very comprehensive indeed. So, we hear about problem areas that many people are preoccupied with when it comes to losing weight. How about the most common areas patients want addressed after weight loss when it comes to skin removal? Are they the same areas, or maybe are there one or two that they focus on even more?

Ayesha Punjabi, MD: The four most common areas are the abdomen, chest, thighs, and arms. I would say that most commonly the area that bothers patients is the abdomen, because the skin in that area kind of folds on itself and can cause a lot of symptoms for patients.

Host: Gotcha. And so, how can excess skin in those areas affect someone in terms of their health physically, not just cosmetically in terms of the way it looks? And of course, it's probably the latter part that people focus on most, but what about the rest?

Ayesha Punjabi, MD: So, The Lion's share of the surgeries that I do are medical and to control symptoms and are covered by insurance. And again, taking the abdomen as an example because it's the most common area. With that overhanging skin, the most common symptom is rashes. Rashes and infections beneath the skin that's just constantly rubbing on itself all day, honestly.

And I have patients, you know, they've tried everything, prescription powders, ointments, creams, and they just always have rashes, even wounds, infections in the area of skin that's folding on itself. There can be pain associated with the extra skin. There can be issues with the posture. There can be back pain from having to support kind of non-anatomic deposits of extra skin, so upper back pain from the chest, lower back pain from the abdomen.

And then, just in terms of kind of functional activities, I've had patients tell me that their extra skin is a burn risk when they're cooking because it gets in the way of the stove. And symptoms that people almost might not think about, but these are real functional problems. Yeah.

Host: Yeah, I can imagine there are indeed situations that many people don't even consider. And so, what types of procedures can be used for this skin removal or body contouring after weight loss? How do you address it?

Ayesha Punjabi, MD: Surgically, these procedures are not the most complex. It involves just making a long scar and removing the extra skin. And there's no way to remove the skin without a long scar and a long wound, which is what makes these big surgeries. And there are patterns to the scars.

So for example, on the abdomen, the most common scar is just across the lower abdomen as low as we can make it so that it can kind of hide in the patient's clothing. But there are just very common patterns to the scars that are most effective to address the excess skin.

Host: I guess it's important to get that point about scarring out of the way. And so, that being said, how do you help patients in general, Doctor, to understand what surgery can realistically improve and what it can't? I guess it's important to make that point that you mentioned that this isn't a perfect world here. We're trying to improve things, but nothing is perfect, right?

Ayesha Punjabi, MD: First of all, these are happy surgeries, despite everything that I'm about to say. They create a big improvement for patients. And the thing that they most reliably improve are those medical symptoms that we talked about. So, removing the overhanging skin on the abdomen will very reliably take care of rashes that are occurring beneath that skin.

The way that I explain it to patients is, number one, when we make a scar to remove the skin, everywhere around the scar, above the scar, below the scar, to the sides of the scar, is technically away from where we are treating. And the further away you get from the scar, the more kind of areas of fullness you can still have.

The second thing that I explain is that when we cut off this extra skin, we have to be able to sew the patient up and get the wound to heal after. And if I pull the wound so tight that I kill the skin trying to put stitches in it, the wound will never heal. So, we have to be careful about how much we remove. We have to be safe about how much we remove, and not tighten up the skin so much that the patient can't heal. And so, that limits how much we can remove.

Host: Understood. Couple other questions for you. Speaking of healing, which you just mentioned, what should patients know about recovery after this procedure, the scarring, and the overall timeline for healing? What can they expect both in terms of how they'll look, but maybe more importantly, how they'll feel, right?

Ayesha Punjabi, MD: One thing that we haven't gotten to yet is I do recommend treating these areas, abdomen, chest, arms, thighs. I recommend generally treating them one surgery at a time, which I know it's, it's hard for patients to hear because it can mean a couple of separate surgeries. But the reason why is, say that we just treat the abdomen. That's a two to three-hour surgery. It's an outpatient surgery. The patient's able to go home same day. For all of these surgeries, kind of no matter what we do, the patient's able to walk around after surgery. even the night of surgery, they're able to eat, drink. And the first couple of days after surgery are really the most tough, and then patients really start feeling more and more like themselves the week after surgery. Until patients are completely unrestricted and kind of working out, running, jumping, heavy lifting, I say two to three months after surgery, and that's when we start talking about, "Okay, is there another surgery that you want to treat another area?"

Now, contrast that, you know, it is technically possible to do the abdomen and the chest at the same time, for example. And you know, if the patient really needs me to do it, it is safe to do. However, we're talking several hours of surgery, probably about an eight-hour surgery. We're talking a likely overnight stay in the hospital, and we're talking minimum double the scars and double the healing. And so, the recovery process, it becomes a lot more tough.

And so, I really, you know, it's the type of thing where if patients really want it and they know what to expect, we can consider it. It's not based upon the plastic surgery literature, you know, dangerous to do, but it's a much worse experience for the patient, I think. And so, tthat's kind of the recovery and how the recovery can vary depending upon our surgical strategy.

Host: And then, just briefly in terms of scarring, I mean, any of us that have had surgery scars know naturally they get better over time. The question is how much better and how long? So, what can people expect there? I mean, I know that, you know, just generally speaking, sometimes, for instance, an abdominal scar for different types of procedures, not just this one. It might take a year or more for that last small percentage to finally heal, right?

Ayesha Punjabi, MD: I actually consider it in two phases. The first is healing, and the second is the scar maturing. So first of all, even just getting the scar healed with these surgeries, because it is such big incisions and scars, it can take several weeks. It's very common for little parts of the scar to open up.

But, you know, in a couple of months, all wounds should be closed. Then, the patient has what I call kind of an immature scar. So it's still pretty pink, pretty hard. And over a year, the scar softens up and becomes paler. And so, that's called scar maturation, and that takes a year. But again, you know, the wound part and the healing part is the other consideration with doing these surgeries one at a time, because that's it's a lot of wounds to have at once to be working on healing

Host: Yeah, no question about it. And a great job by you to point out why it's so important, if possible, for people to follow your advice and get them done one at a time. In summary here, Doctor, for those joining us interested but maybe a little apprehensive, nervous even, understandably so, about possibly getting this done, what do you want them to know before scheduling a skin removal consultation? What's the most important thing for them to weigh or keep in mind? Weigh, no pun intended.

Ayesha Punjabi, MD: I would say two things. The first thing is that these are completely elective surgeries, so there's never any pressure or urgency to proceed. The point of a clinic visit is just to equip the patient with all of the information that they need to know what to expect from the surgery. That's number one.

Number two is kind of what I mentioned before, that these are actually, even though they're major surgeries, very happy and well-tolerated surgeries for patients. They can kind of drastically improve patients' quality of life. And people actually handle the healing process very well. Even if some parts of the incision open up and they have some wounds that require bandaging for a few weeks, they're shallow wounds, and they ultimately heal. And so, patients, you know, are generally happy that they went ahead with these surgeries.

Host: I'm sure those joining us are definitely relieved to hear that from you. Folks, we trust you're now more familiar with skin removal after weight loss surgery. Doctor, an important topic as we pointed out earlier. Keep up all your great work and thanks so much again.

Ayesha Punjabi, MD: Thank you.

Host: And for more information, please visit swgeneral.com. If you found this podcast helpful, please do share it on your social media. Thanks again for being part of Southwest General Health Talk.