Steve Mellon, Post-Gazette Sally Stewart shed 150 pounds, but that was only part of her weight-loss journey. Surgery was required to remove large folds of extra skin, which had been stretched so long by the excess pounds that it had lost its elasticity. Click photo for larger image. Related story Body contour surgeries on the rise

Like most people who have turned to gastric bypass surgery to treat morbid obesity, Sally Stewart was thrilled with the initial results. Within 18 months of her July 2002 operation, the Brookline resident had shed half of her body weight -- a whopping 150 pounds -- and had gone from a size 26 to a 10.

Serious weight-training, aerobics and daily yoga, though, did little to tighten the huge amounts of loose, sagging skin that hung off her body, Shar-Pei style.

Though she could cover with clothing the disfiguring, three-inch-long folds of flesh that dangled from her waist, they still bothered her. A lot.

"It was a real source of frustration," admits Stewart, 41. "I'd put a lot of work into toning my body, but I couldn't see the results."

Her knees, in particular, looked like an elephant's, and when she worked out on the elliptical runner, the extra skin on her thighs would fly up and almost clap.

She also experienced recurrent infections in her belly button, where the skin folded over, as well as occasional rashes in the crease under her belly.

"My original goal was to be healthier and more active," recalls Stewart, an administrative assistant at Carnegie Mellon University, "but I felt like this weight was dragging me down. It might have just been skin, but it was a lot of skin. It felt almost like an appendage."

Charlee Brodsky Sally Stewart is documenting her weight loss journey on a Web site called Reconfigured, in collaboration with Charlee Brodsky, a Carnegie Mellon University professor who teaches photo-design and photography. It is a work-in-progress that will eventually be published as a book. (Brodsky was also the visual collaborator in the highly regarded Stephanie project, a documentary of one woman's experience with breast cancer.) In addition, Stewart has started an online peer support group. Click photos for larger image.

Like a growing number of post-bariatric patients, including celebrities like Carnie Wilson, Stewart turned to plastic surgery to remove the extra folds and finally get herself looking -- and feeling -- normal.

In December, Dr. J. Peter Rubin, director of the Life After Weight Loss Program at the University of Pittsburgh Medical Center, performed an abdominoplasty (commonly called a tummy tuck), a lower body lift and a medial thigh lift. During the 10-hour surgery that involved an incision from hip to hip and hundreds of stitches, Rubin removed 10 pounds of skin. She was in the hospital for five days.

"I sometimes can't believe it," says a delighted Stewart, who lost 4 inches around her waist from the surgery and can now slip into a size 6. "For the first time, it's fun to go shopping. I even got a bikini, which I've never had in my life."

She looks so good that she was a model in a recent "before and after" bariatric fashion show sponsored by a local medical device company. Stewart also is the cover girl for a winter edition of WLS Lifestyles, a magazine about weight loss surgery.

Rubin, who performs six to eight body contouring procedures a week, agrees surgery can make a huge difference. Losing the pounds may erase the weight-related illnesses such as diabetes and hypertension, but you won't look like a model. Skin loses its elasticity when it's stretched too far, and won't shrink back. In some patients, the "apron" of skin that hangs down from the lower abdomen will cover genitals, thighs and even knees.

"It affects your self esteem," Rubin says. "To let go of the image of an obese person, you need to get rid of the daily reminder of hanging skin."

Studies are under way to see whether the amount of loose skin that results is tied to the speed of weight loss -- it's much more rapid after gastric bypass surgery than after traditional caloric reduction -- but Rubin believes it's probably related more to the number of pounds dropped. Skin elasticity also can be influenced by genetics, age, sun exposure, smoking, systemic diseases and some medications.

Lots of lifting

People have long battled aging with tummy tucks, breast lifts and liposuction. Body contouring surgery following massive weight loss, though, is an emerging field in plastic surgery, as new techniques have been perfected and surgeons have learned to integrate several procedures.

Dr. Dennis Hurwitz of the Hurwitz Center for Plastic Surgery in Oakland, has pioneered what he calls the total body lift. The eight- to 12-hour surgery, which includes gentle liposuction to eliminate fat, removes skin on the upper abdomen, hips, back, buttocks, arms and thighs and reshapes the breast. The procedure can also be broken into two phases if the patient isn't in great physical condition.

"I'm correcting a deformity," says Hurwitz, who sees patients from around the country. "In our society, looking good is a high priority. These people are at a huge disadvantage."

Most of the operations are cosmetic; elephant-skin knees, saddlebag hips and droopy upper arms don't cause any health problems.

Abdominoplasty, the removal of skin around the stomach and tightening of muscles of the abdominal wall, may be performed for medical reasons. Moisture between the skin folds can cause chronic rashes and infections. If the apron is large enough, a person can have difficulty standing or walking upright; it can also create hygiene problems and cause lower back pain.

Still, for many of these patients, body contouring has very little to do with a desire for a sculpted arm or ultra-slim thighs. It's just about looking normal. Or as Hurwitz puts it, "Before losing weight, they were fat, happy people. Now they're grumpy, with deformed, hanging skin, a situation that may make them more inhibited in social and intimate situations than ever before."

Completing a process

For others, it's about bringing the weight-loss process full circle.

Like Stewart, 37-year-old Chris Bryan took off 150 pounds after gastric bypass surgery in 2001. But it also left her with two rolls of excess skin on her belly, despite a strenuous exercise regimen.

"As happy as you are to weigh less, at some point you think: but I have all this hanging skin," she says. "It got to the point where I was tucking my stomach into my pants."

Liposuction 19 months after the bypass removed a liter of fat; another operation two months later removed the baggy skin in the abdominal area. This produced a scar that stretches from hip to hip and a new belly button.

"I consider it part of my evolution to lose all this weight," says Bryan, who said the skin surgery pain was awful. "It's like, I've worked really hard to get this far, I need to keep going."

She eventually wants to get her arms tightened and a breasts reduced.

The surgery isn't without risks. In addition to the risks associated with general anesthesia, patients can experience a lot of pain, excessive bleeding during and after the operation as well as seroma, an accumulation of fluid under the skin after the drains are removed. There also can be infection, wound separation, blood clots, a change in skin sensation and delayed healing. Recovery lasts three to eight weeks.

"It must be so important to them that they are again risking their lives," says Hurwitz.

"These are very big operations," agrees Rubin, who notes the ideal patient has a stable weight, is motivated and is in good mental and physical condition. "It can't be done casually."

Scarring

Perhaps the most negative outcome is the extensive scars. While they fade over time, and surgeons do their best to position them where they are least noticeable, it's not an exact science; much depends on genetics and age. Prospective patients must also realize that the results may fall short of what they expect. No matter how talented, surgeons can't always get rid of every piece of sagging skin or pocket of fat.

Costs are rarely covered by insurance.

		Web resources For more information: American Society of Plastic Surgeons, 444 E. Algonquin Road, Arlington Heights, Ill, 60005, 1-888-475-2784. www.plasticsurgery.org American Society for Aesthetic Plastic Surgery, 36 W. 44th St., Suite 630, New York, N.Y. 10036. Referral service, 1-888-272-7711. www.surgery.org

Phyllis Stern of Lawrence-ville, who lost 150 pounds through Weight Watchers, had to go before her insurance company three times before it finally approved surgery last summer to remove the apron on her stomach that was causing chronic infections and boils. She is waiting to hear about a thigh lift later this year.

Despite a long and painful recovery -- it was eight weeks before she felt "normal" -- and a 36-inch scar, she's ecstatic with the results.

"Now people can pat me on the top of my thigh and not hit my stomach," she says with a laugh. "And when I sleep, there's no excess skin pulling me down."

Sally Stewart, who paid $9,000 out of pocket for the first operation, plans to have to additional surgery when she has the money. The skin hangs down so far on her arms that she has to buy over-sized shirts.

"I want to finish the job. It's been a dream come true for me. I feel like I have my life back, and can live the life I want to live."