Minimize Excess Skin After WLS

What Can Be Done To Minimize Excess Skin After WLS

May 20, 2019

There are many myths and urban legends when it comes to reducing the excess skin after weight loss. Some people suggest fantastic creams or magical lotions, while others suggest only losing a certain percentage of fat over a specific amount of time. Since there is so much confusion, first let us look at something concrete like the anatomy of the skin.

Skin Anatomy After Weight Loss

The amazing human body is composed of many layers. From the outside inward, basically, there is skin, fat, fascia, muscle, and bone. With weight gain, there is fat accumulation in two distinct locations. These two distinct pockets of fat are divided by the peritoneal cavity. The peritoneal cavity is a cavity that extends from your lower rib cage and diaphragm to your pelvis. The peritoneal cavity is bounded anteriorly by the rectus abdominis muscle and posteriorly by the spine.

  • Extraperitoneal fat is a medical term to describe the fat outside the peritoneal cavity or the fat just under the skin.
  • Intraperitoneal fat is another medical term used to describe the fat inside the peritoneal cavity.
  • The stomach and the small intestine live in the peritoneal cavity.

With weight gain, there is a collection of fat around the stomach and intestines and development of intraperitoneal fat.

This intraperitoneal fat pushes the abdomen from the inside. The intraperitoneal fat cannot expand against the spine, so the intraperitoneal fat pushes against the abdominal muscles (rectus abdominis, external and internal obliques). This anterior push of intraperitoneal fat causes the abdomen to become distended and protuberant. This intraperitoneal fat causes the muscles, covering of the muscles (fascia), and the skin to be stretched and distended.

With weight gain, the extraperitoneal fat (or fat under the skin) pushes in all directions. The extraperitoneal fat is bounded on the top by skin and underneath by the fascia covering the muscle. Since the skin that is enveloping the fat is less resistant than the underlying fascia, the fat pushes the skin outwards.

Thus, the skin is pushed and expanded by both intraperitoneal and extraperitoneal fat. Fortunately, the skin has many unique qualities including the ability to expand.

The skin can expand because it has elastic fibers that allow it to stretch. These skin elastic fibers are like rubber bands.

If your skin is stretched too much during weight gain, the elastic fibers in the skin can tear and break. These broken elastic fibers can be seen in the skin as stretch marks. Therefore, stretch marks are really scars reflecting elastic fiber rupture.

Skin stretchability is critical for growth from infancy to adulthood and during pregnancy. Also, due to the skin being stretched, there is an actual increase in the number of skin cells. This means that during the skin stretch associated with fat accumulation, there is also an increase in the sheer number of skin cells.

So, the skin can stretch due to the elastic qualities of the skin. How does the skin recoil or bounce back after massive weight loss?

The internal anatomy of each structure affected by fat accumulation is critical to understanding the skin situation after massive weight loss.

Remember those elastic fibers in the skin? After massive weight loss, it is those same elastic fibers which help to snap the skin back. These elastic fibers are like a rubber band that has been placed on a stretch with weight gain. After the weight is lost, there is reduced tension on the elastic fibers and the elastic fibers contract leading to skin contraction. Elastic fibers are the primary and most important reason for skin contraction.

In addition to elastic fibers, the skin contains cells called fibroblasts that reside in the deep layer of the skin called the dermis. In addition to making collagen, fibroblasts assist in skin contraction. Fascia and muscle also contain fibroblasts, but in a lesser amount compared to the skin. These fascial and muscle fibroblasts are thought to assist to a much lesser extent in skin contractility. That is how the skin retracts after massive weight loss.

Internal and External Factors that Affect Skin Contractility

Many other factors influence skin contractility. There are internal and external factors that affect skin contractility.

Internal factors:

  1. There are several genetic conditions which influence skin contractility. These include cutis laxa, elastoderma, and Ehlers-Danlos syndrome. These conditions are rare, but all can affect skin elasticity.
  2. Several hormones can influence skin contractility. Skin contractility is affected by your blood androgen, cortisone, thyroid, and estrogen levels. Elevated glucose levels can cause free skin damage and impede skin circulation. Altered levels of these hormones can alter your skin’s ability to contract and heal.

External factors

  1. The number of times the skin has had to bounce back (think yo-yo dieting here!) the more times you stretch those elastic fibers, the less likely the fibers are going to retract.
  2. The sheer amount of skin stretch can affect the amount of recoil. The more weight you were at your maximum weight, the less likely the skin will completely recoil.
  3. Physical age of the skin will affect the ability of your skin to recoil. The older you are, the less likely your skin can recoil. Loss of skin recoil ability due to age is thought to be due to decreasing amounts of elastic fibers, collagen, and fibroblasts.
  4. Amount of sun damage to the skin will slow skin contractility. Sun exposure causes radiation damage to skin DNA and decreases the skin’s ability to repair itself. The sun accelerates collagen damage and reduces the ability of the elastic fibers to contract.
  5. Smoking causes free radical damage to the skin.

All these factors add up to what we call your “skin age.” Usually, skin age does not correlate to chronologic age. Due to all these internal and external skin damaging factors, most people’s skin age is older than their real age. Think of those sun worshiping, smokers with their leathery facial and neck skin who look much older than they actually are! All the bad things like weight gain, yo-yo diets, poor nutrition, sun exposure, smoking, and genetics, all contribute to an advanced “skin age.”

Inaccurate and False Information

Unfortunately, the internet is full of inaccurate and false information in regards to maximizing skin recoil after massive weight loss. These false beliefs are unfortunately spread to unsuspecting weight loss patients in hopes of a magic solution.

Some proposed ideas include a slow and steady weight loss of one or two pounds a week. They state that the quicker you lose your weight, the more likely you are to have a problem with excess skin. This is not true. Losing weight at a specific rate does not increase your skin’s ability to recoil.

Others state that you should build muscle to shape the tissue underneath the sagging skin. This is also untrue because it would be impossible for you to build up your rectus abdominis muscle to completely fill your overlying, hanging abdominal skin. Another practitioner suggests using a soft boar bristle brush before bathing or showering. They say this increases circulation to the skin. However, this too does not enhance your skin’s ability to recoil. Others suggest a weekly massage and hot (but not cold for some reason) saunas; it may feel good, but it does nothing for skin contractility.

There are also countless high-quality skin lotion, vitamin E oil, and magic skin tightener with hundreds of upstanding recommendations by models. Nope, unfortunately, these don’t work either.

Other magical machines include fancy lasers, LED lights, and derma-rollers. Others swear by a specific corset garment with whalebone inserts. Recently, others have suggested cool sculpting and HCG shots to decrease hanging skin after weight loss. Unfortunately, none of the items mentioned in this paragraph have been medically proven to increase the ability of the skin’s elastic fibers to contract or enhance the ability of the skin’s fibroblasts to contract.

What You Can Do To Minimize Excess Skin After WLS

So what are you going to do? Unfortunately, you cannot change your genetics. You cannot reverse those years of being overweight. You tried to control your glucose levels and stop smoking.

So in conclusion, I would offer the following advice.

Lose your extra weight now. Get healthy now. Do not worry about the excess skin. There is not much you can do about the way your skin will hang. We do know from the medical data that the younger you achieve a healthy weight, the better in terms of the overall health and ability for the skin to recoil. During your weight loss journey, eat a healthy, balanced diet, exercise regularly, and take daily vitamins.

Check your hormones levels, especially your thyroid and adrenal glands. It is impossible to predict what your skin will look like after your weight loss. Just go with the flow. Once you have achieved your weight loss goal and if your excess skin bothers you, please seek a board-certified, plastic surgeon who has significant experience in reconstructive plastic surgery after massive weight loss.

timothy katzen


Dr. J. Timothy Katzen is certified by the American Board of Plastic Surgery, and is the President of the American Society of Bariatric Plastic Surgeons. Dr. Katzen specializes in reconstructive plastic surgery after massive weight loss. He has written many articles and given lectures around the world about how to perform plastic surgery on patients who have undergone massive weight loss. Dr. Katzen has plastic surgery offices in two different states and two different countries. Specifically, he has offices in Beverly Hills (California), Las Vegas (Nevada), and Dubai (United Arab Emirates). Read more articles from Dr. Katzen!