In the anterior abdomen of the massive weight loss patient, the skin fold over the lower abdomen is large and called an apron. It often drapes downwards past the mons pubis causing hygiene and sexual issues. An abdominoplasty, which is defined as the correction of anterior abdominal wall skin redundancy with undermining of flaps to allow repositioning of the umbilicus and plication of the rectus abdominus muscles is indicated. The scar runs from hip to hip and is concealed within the bikini line. 

Some patients aren’t ready for an abdominoplasty as they haven’t reached their ideal weight, yet their abdominal apron is large enough to bother them and cause hygiene issues. In these patients, an apronectomy may be indicated. In this procedure, the anterior abdominal skin fold is removed without undermining the skin flaps and may include removal of the umbilicus but no repositioning. The lack of undermining means that the abdominal shape is not as contoured as an abdominoplasty, however the removal of the apron is functional.

In many cases, the excess skin of the anterior abdomen goes around the sides to involve the flanks and lower back, causing descent of the outer thighs and buttocks. In this case a modification of an abdominoplasty, which goes around the flanks and lower back is recommended. This is termed a belt lipectomy or circumferential abdominoplasty as the scar goes around the waist like a belt. It also allows the surgeon to lift tissues below the waist, namely the descended pubis, outer thighs and buttock, where is therefore termed as a lower body lift.

This surgery starts off in a prone position, whereby the excess lower back skin to be removed. A gluteal augmentation may be performed by using the fat of the tissue which would have been discarded to be placed in a pocket created in the buttock. This is to provide a waist, because sometimes when the buttock is pulled upwards, it may be flattened. The patient is then turned supine and the abdominoplasty proceeds as described previously.

In some patients, there may be excess tissue both below and in front of the abdomen. In this case, a Fleur de Lis abdominoplasty may be indicated, resulting in an inverted T shaped scar along the midline and the bikini line. The umbilicus is inset along the vertical scar.

In the arms, the excess skin hangs below the lower border of the arm, and in severe cases goes past the axilla down the side of the chest, taking on a bat's wing appearance. A brachyplasty (arm lift) for this might involve excising the redundant skin of the upper arm and lateral chest resulting in a slender arm and tighter chest.

The breast droops severely in a massive weight loss patient. This is a combination of volume loss from fat and glandular atrophy combined with the loss of skin elasticity. The breast is deflated and has a flattened side profile that is empty in the upper pole with striations on the skin. The lower pole hangs down on the abdomen with the nipple way below the inframammary fold. 

A mastopexy (breast lift) helps to restore a more youthful breast by lifting the nipple areolar complex and breast tissue to a more ideal location and excising excess skin. There are many techniques depending on the degree of severity. In the massive weight loss patient, it usually results in an inverted T scar that goes around the areola, down the midline of the breast and along the inframammary fold, that’s called a Wise Pattern. 

In a male, gynecomastia may develop with excess skin that drapes below. Liposuction removes the fat through concealed incisions if necessary open excision may be performed through an incision along the areolar. If the skin excess is a problem, it may be excised in the same stage or in a second stage surgery.