Not infrequently I am asked what is the best timing for removal of excess skin after weight loss surgery.

First of all, lets keep in mind that this is a good “problem” to have. It is not really a matter of excess skin after weight loss surgery so much as a big reduction of the excessive fat. In the years prior the skin will have stretched to accommodate the excess body fat and it often lacks the elasticity to bounce back to a normal, nice shape following big weight loss.

A few factors that determine how much “excess skin” are a persons age, how much weight the person gained prior to weight loss surgery, and the sun exposure over ones lifetime to that skin (ultraviolet sunlight exposure reduces the elasticity of the skin).

Of course the question of whether or not to have the excess skin removed is really a question of whether or not the individual in question is OK with having what is essentially cosmetic plastic surgery. This is definitely a personal decision and one that no two people will look at quite the same. So without a lot of discussion about our body self images and what does and does not really warrant plastic surgery, lets cut to the question as to when is the optimal timing, assuming that you did want to undergo plastic surgery somewhere down the road after your terrific weight loss? (In our practice somewhere around 1/3 of patients do undergo some type of plastic surgery within five years after their bariatric procedure).

The answer, I think, is this: once you have reached your goal weight.

So this means that you must establish a goal weight and then it means that you must stick to that goal, work hard at achieving that goal and once you have achieved it consider that the optimal time frame for undergoing plastic surgery for excess skin. The reasons for this are that you do not want to do it too early before your body has reached its best possible shape lest you would have to do it again. For most people this means waiting a minimum of eighteen months and many times waiting an even longer period of time. If you are like the average person who undergoes Roux-en-Y gastric bypass surgery you may want to wait twenty-four months to reach your best goal weight. If you are undergoing laparoscopic adjustable gastric banding surgery you may want to wait thirty-six months since so many people continue to lose weight between year two and year three. You may want to wait even longer!

But, my bottom line, wait until you have reached your goal weight. If you like to have rewards for yourself and plastic surgery is something that is important to you then consider it a major reward for yourself when you do achieve your goal weight.

An interesting phenomenon I have seen in recent papers reporting long-term outcomes is a disparity between some programs that are heavily devoted to gastric banding and programs that emphasize gastric bypass more. Perhaps predictably, the programs that are very “pro-band” tend to report better weight loss outcomes than centers that emphasize gastric bypass surgery.

There are always multiple reasons for discrepancies in data in any kind of medical studies or scientific trials. But, as our own center has matured over the years and as banding has become an increasingly important component of what we offer, I think there is an important and possibly overlooked explanation for the differences in the long-term weight loss results reported by different studies. And here it is: programs that emphasize gastric banding as a weight loss solution must invest heavily in the long-term follow-up program. For us, this has meant hiring and retaining outstanding nurse practitioners, physician assistants and dieticians who serve on the front lines and see the majority of the patients long-term for their follow-up, band fills, encouragements and coaching. The regular weigh in’s, the accountability this brings, and the opportunity to do ongoing metabolic testing, vitamin testing, counseling and coaching is invaluable in the long-term weight loss success for band patients.

In the future I am confident that our program will be able to demonstrate long-term weight loss results among thousands of gastric band patients that are equal to the outstanding results that we have achieved in the last decade with gastric bypass surgery. I think the infrastructure, personnel and long-term follow-up program will enable those results just as it has for some other centers around the world.

Increasingly we have seen reports in the literature from outstanding centers that demonstrate the long-term weight loss results after gastric banding surgery (Realize band and Lap-band) are equivalent to the long-term weight loss results after gastric bypass surgery.  What occurs is that weight loss is more rapid and greater in magnitude in the first year after gastric bypass surgery, but this gap narrows significantly at the second year of follow-up.  By the third year the difference becomes quite small and may, in fact be indistinguishable.  Then in years four, five and beyond the average maintained long-term weight appears to be the same between the two groups in these studies.

In other studies from programs and centers that focus a bit less comprehensively on long-term band follow-up and care, the results after gastric bypass surgery continue to show a weight loss advantage in favor of the bypass.  The gap at year one is narrowed, but even in the long-term their remains an advantage for the gastric bypass arm and of course this advantage does translate into some improvements or advantages in other health conditions such as obstructive sleep apnea, hyperlipidemia, hypertension and diabetes.

So what accounts for the difference in these studies? While we can’t be certain, and of course there is always variability in any such long-term studies looked at from different centers and different perspectives, I believe the answer may lie in the diligence with which the band patients are followed and the dedication to Lap-band follow-up exhibited by those programs.

What I mean is that patients undergoing gastric banding surgery may have two very different experiences: on the one hand they may go to a center that has outstanding long-term follow-up and have enthusiastic and knowledgeable physicians assistant, nurse practitioners and dieticians  who can coach, council and encourage patients to continue their weight loss journey over the long-term while also skillfully making band adjustments in the office.  The program likely also has support groups and may have other features such as special events, walking groups and celebrations.  All of this combines to create an environment that is conducive to long-term weight loss success.  On the other hand, the patient may go to a center where surgery is performed and very little follow-up is involved.  (An extreme example would be a person who leaves the country to save money in the short-term, but fails to have taken advantage of the long-term follow-up features that lead to success.)  Several studies support this notion that the level of participation in long-term follow-up and the commitment to band adjustments by both the patient and the program, are critical to long-term success.

Our program has fought to enhance its long-term, follow-up features by creating walking groups, special events, support awareness of childhood obesity prevention, a celebratory fashion show, and enthusiastic coaching and encouragement with frequent open access band fills.  In the future I hope that our center might also report data which demonstrates the long-term weight loss results with gastric banding are indeed comparable to the long-term weight loss results after the outstanding results of gastric bypass surgery, which we have previously reported.

An interesting study just released looks at the long-term remission rates of type 2 diabetes mellitus after laparoscopic adjustable gastric banding.  The study reported by Dr. Samuel Sultan demonstrated that after five years of follow-up 40 percent of previously diabetic patients were now off of all diabetes medicines and had normal blood sugars and normal hemoglobin A1c levels.  In a total of 80 percent of patients the diabetes was improved (as defined by a reduction of diabetes medicine) or was totally resolved.

Not surprisingly the patients in the study who maintained the resolution of their diabetes were the same patients who maintained their weight loss over that time period and who exhibited a greater magnitude of weight loss at the five year mark.

I think what this study says about long-term resolution of diabetes after lap-band surgery is that the key is, in fact maintaining the weight loss for the long-term.  We know that the keys for maintaining that weight loss long-term are committing fully and completely to changing, adapting a new life style, participating in ongoing long-term follow-up with the bariatric surgeons office and continuing to have band fills and adjustments on a regular basis.  We also think that coaching, attendance at a support group and more active participation in activities, such as regular walking groups, contribute to the long-term success that leads to total, long-term resolution of diabetes.

The choice of which bariatric procedure on should choose to do is an important one, but it might not be as important as you think.

When faced with deciding upon the right weight loss surgery for you there are many choices to consider. One should try and research every detail they can about them and make the best possible choice for themselves.  I have written a lot on this blog, in books, and articles regarding how to go about choosing the right surgery. I have examined the data very carefully to try and help guide people on this topic.  I also spend a lot of time one on one with my own patients in trying to help them make the best decision should they choose the laparoscopic Roux-en-Y gastric bypass, or perhaps the laparoscopic adjustable gastric band or the laparoscopic sleeve gastrectomy.  Sometimes the choice can be difficult and as we know there is no single, one clear cut right answer for everyone.

But, more important than the choice of weight loss surgery is a much richer, more challenging and more rewarding place to focus our mental energies: on staying prepared and motivated to do the work of losing the weight.  Regardless of what surgery is chosen, the procedure is not going to do the work by itself.  No surgery is going to magically make a person exercise more, decrease the glycemic index of their intake, reduce their portions and begin cutting out full meals and servings of carbohydrates such as: sweets, desserts, potatoes and snacks.  Only you can do that.

So while choosing the proper surgery is important, and some people may do much better with one kind of procedure than another, at the end of the day the variations and weight loss outcome between all the operations is dwarfed by the variations between individuals depending on their motivation level.

Yes, that is right, you could lose far more weight with the less invasive procedure simply by being more motivated and sticking to the regimen more closely.  That means dramatically cutting down carbohydrate intake and increasing the calories you burn with muscle activity.  On the other hand, you can have the most invasive operation that supposedly delivers the highest amount of pounds lost, and find that you don’t lose any weight because you are less motivated and less compliant with the recommended eating regimen.

If the difference between say, the gastric bypass and the gastric banding procedure in terms of average weight loss results is ten percent, the difference between highly motivated and less motivated individuals is 100 percent.

So, research as much as you possibly can.  Read the articles on this blog about the subject, read my book about which operation is right for you.  Read every other source you can, talk to as many people as you can.  But, once you have made a decision about which procedure to undergo, focus all of that mental energy and enthusiasm (and more of it!) on committing 100 percent mind, body and soul to achieving success in your weight loss journey.  This is going to mean sacrifice.  It is going to mean starting a difficult preoperative weight loss diet.  It is going to mean living with hunger.  It is going to mean making painful choices.  It is going to mean cutting down the carbohydrate intake.  It is going to mean reading every label.  It is going to mean increasing your muscular activity through things like: walking, swimming, use of hand weights, etc.  It is difficult, but with a consistent and dedicated effort you can achieve amazing results no matter which type of surgery you have chosen.

I am occasionally struck by the comments from medical physicians or from people in the health care community who comment that some of what I do to help people lose weight and solve their diabetes is so “radical”. Usually when they say this they are referring to Roux-N-Y-Gastric Bypass surgery, which does involve a fairly permanent rerouting of the stomach and upper intestinal system. Even though the procedure is done with a laparoscopy, or minimally invasive technique, and usually involves a one hour surgery and overnight hospital stay, I certainly agree that it is a major decision to undergo the procedure and not something to be taken lightly.

I am ,however, troubled by the real lack of understanding of the nature of the diseases of both obesity and diabetes among those making this kind of comment. I have even had, for example, people in my office who were considering weight loss surgery and brought along their skeptical spouse or significant other to talk with me. Here I would be, speaking with a person who has tried for decades to lose weight and is now seriously overweight struggling with insulin shots, umpteen medications, severe pain in the spine and weight bearing joints, high blood pressure, breathing difficulties and yet the spouse or significant other would be very discouraging, saying things like, “the surgery is too radical”. I wonder just what solution would be appropriate given the “radical” nature of the disease that is leading to such diminished quality of life for the person in such a dramatic shortening of life span with early onset of these devastating diseases. What we seek in medicine and all health interventions is proportionality wherever possible. This means that we prefer that the treatments, or intervention, be proportional to the seriousness of the disease. For example, radical brain surgery would only be considered appropriate if the disease being treated was a life threatening brain tumor. We would not recommend craniotomy surgery and its attendant risks and recovery time for a less severe brain condition, like say, headaches.

So, is weight loss surgery a proportional treatment for this disease? I would argue that it is quite acceptable in terms of this concept of being proportional, especially when compared to so many other kinds of treatments across the spectrum of so many other diseases. And especially as weight loss surgery has moved increasingly to the minimally invasive and even to the outpatient realm, it has become far less radical than the disease it treats and in many cases cures.

Vitamin D and calcium are very interrelated because they both work together in maintaining the calcium levels in the bloodstream and are very important in the maintenance and production of strong healthy bones. Vitamin D is a fat-soluble vitamin, and it is found in milk and eggs and some fish and some liver. Calcium is present in virtually all dairy products and calcium deficiency is common after gastric bypass surgery and it is more common, we believe, among women than it is among men. Calcium and vitamin D are being studied actively all the time because they are so important for bone metabolism and it is believed that the very common problem of osteoporosis or thinning of the bones is related to the deficiencies of calcium and vitamin D. Vitamin D deficiency does result from any sort of malabsorptive procedure, such as a biliopancreatic diversion, more with the jejunoileal bypass, less so with gastric bypass, but it is still somewhat possible, and the duodenal switch type procedures as well.

Deficiencies of calcium or vitamin D lead to breakdown of the bone deposits and weakening of the bones in general. The symptoms of vitamin D and calcium deficiency are typically fatigue and pain in the joints and bones, muscle aches, and over time will lead to the progression of osteoporosis. Osteoporosis is bad because it will lead to a greater increase in the risk of fractures. Most people are familiar with osteoporosis when we think of elderly people, especially elderly women falling and suffering a broken hip or a broken leg which is a very serious problem. When weight loss surgery very first became more popular, it was not recognized that vitamin D and calcium were likely to be deficient and it was really an under reported and under recognized problem until recently. Now I think we realize that calcium and vitamin D both should be supplemented and monitored after gastric bypass surgery, and even more so after biliopancreatic diversion or more malabsorptive type procedures.

Vitamin D needs to be converted to an active form with exposure to sunlight to the skin, so interestingly, the healthier we feel and the healthier we are and the more active we are outside in the sunshine, then the healthier our bones tend to be. So something in there that our mothers probably taught us about being outside and active and getting a little sunshine was really true in preventing osteoporosis and vitamin D and calcium deficiency. We recommend that everybody supplement calcium and vitamin D with 1200 mg of calcium daily and the vitamin D supplement of around 8 mcg. There are several commercial pharmaceutical grade vitamin and mineral supplements that have this combination or they can be supplemented separately. We have gradually added lines of vitamins and minerals to our own programs to specifically supplement patients who have undergone weight loss surgery.

Vitamin K is one the fat soluble vitamins. It is generally present in green, leafy vegetables like spinach. Deficiencies of vitamin K result in specific problems related to blood clotting, so our circulating blood consists of the cells, but also a number of proteins that bind together to create blood clotting and stop us from bleeding if we have a cut or an injury. So with a vitamin K deficiency, that mechanism of creating blood clots is damaged and it leads to prolonged bleeding with bruising and sometimes bleeding of the gums and other sites. Vitamin K deficiency is rare except again after the malabsorptive procedures like the biliopancreatic diversion or the old jejunoileal bypass. It is not commonly seen at all after gastric bypass surgery or Lap-Band surgery. It is not tested routinely. We don’t generally recommend routinely testing vitamin K levels, but if you’ve had had one of those highly malabsorptive procedures then vitamin K deficiency could result. The same can be said for vitamin E. Vitamin E is another of the fat soluble vitamins. It too is found among green, leafy vegetables, as well as nuts and seeds and some vegetable oils. Vitamin E deficiencies are very rare and they generally would result in symptoms related to the nervous system. It is not generally tested, nor is it necessary to monitor it or have specific supplementation of vitamin E, but again, it is helpful to be on the radar screen for people who are having a lot of problems with absorption of fats either due to medications or due to a malabsorptive weight loss procedure.

I have a few more posts about vitamin deficiencies. Today I want to briefly discuss Vitamin B6.
Vitamin B6 is known as pyridoxine and it is present as a water-soluble vitamin in meats, as well as beans, some legumes, whole grains, and some nuts. B6 is rarely tested for, but it turns out that many of us are deficient in vitamin B6 and if we were to test everyone prior to surgery, we would find that probably at least several percent of our patients considering weight loss surgery actually already have deficiencies in vitamin B6. It becomes more deficient after gastric bypass surgery or other malabsorptive operations, but not as commonly as a vitamin B12 deficiency. It is generally included in the standard multivitamin that we recommend everybody take. This is not a very common vitamin deficiency as a result of a weight loss surgery. Not something people considering a bariatric procedure generally need to worry about specifically.

The next vitamin I want to discuss with regard to deficiences after weight loss surgery is folic acid or what is often referred to as folate. Folate, like vitamin B12, is very important for a number of aspects of metabolism and it’s very important in the production of our red blood cells.

Generally present in beans and green leafy vegetables, it is a B complex vitamin that is water-soluble and it does become deficient more often after gastric bypass surgery. The kinds of symptoms people might experience with a folate deficiency would include weakness, fatigue, pale skin, and possibly a feeling of coolness or cold intolerance. Sometimes there can be other symptoms of this deficiency such as nerve tingling, numbness, and confusion. It’s generally very well supplemented with a standard multivitamin containing folic acid, which nearly all of them do, and in a real severe unusual case it could be supplemented with an IV infusion in the hospital or in an infusion center. Generally speaking, we don’t specifically test for folic acid because it is not such a common deficiency, but we do generally test everybody after surgery at intervals in their three-month, six-month, 12-month and annual follow up visits by checking their red blood cell count. If they are anemic, if the hematocrit or hemoglobin or the red blood cell count itself has fallen, then that might be a reason to go ahead and check the folic acid level, as well as the other vitamin B complex levels. Generally speaking, however, we don’t specifically test folate in everyone just as a routine. If people are taking their standard multivitamin after gastric bypass surgery, then the risk of folate or folic acid deficiency is very low.