Flabby Hanging Skin

Do you want some extra skin "cut out"?

We will skim over what can do to strengthen skin, but if you need it cut out, we'll look at what can be done awake versus asleep under general anesthesia. We'll show you where to learn more about hanging skin on the face and chest area, but this section goes into details on tummy tucks, arm lifts, back lifts and removal of other "extra" skin!

If you have more questions, such as whether a short scar arm lift or a traditional scar would be better for you, just call Pulsar Health in West Palm Beach, FL to book an appointment.

Okay so sometimes crepey skin would be great because we're all the way at flabby. Instead of feeling wonderful about achieving a healthier weight and shedding excess fat, we are faced with the frustration of hanging skin. This can happen for reasons other than weight loss, such as after the joy of a baby, over time in the eyelid, neck and arm area, or after interventions that "went wrong" such as silicone injections. 

When you visit, we can assess the skin to see how much elasticity it has and if that can be helped. Sometimes doing treatments like the Virtue DEEP or SMART radiofrequency microneedling can rebuild the strength and elasticity of the skin and underlying collagen / elastin structures. This can help the results even if you have to have surgery to remove the excess, because stronger skin gives you better long-term results. Also, if it is slightly loose but not hanging, we can consider Renuvion J-plasma for contracting down the tissues 40% to 60%. Thread lifts can also help lift sagging jowls and improve the neck area. 

However, if the skin is truly hanging, the most effective solution is surgery. Surgery does not have to be an ordeal. For a lot of the awake procedures, we try to make it fun and easy for you. Many procedures can be done "awake":

• upper eyelids and some simple lower eyelid surgeries (blepharoplasty)
• jawline surgery such as neck / lower face lifts or MyEllevate lifting of tissues
• excess skin/fat excision including rolls under the armpits
• extra skin just above the pubis
• tummy tucks that move the belly button (but not tightening the muscle lining)
• selected arm lifts 
• some breast lifts / breast reductions

Other surgeries. such as more extensive thigh lifts or back lifts, or a full abdominoplasty (with tightening of the lining of the muscles) are better done under general anesthesia. Awake surgeries are done with numbing medicine injected in, but also some oral medications such as painkillers and antibiotics. We also use laughing gas (pronox) to have you feel more comfortable. Most people are surprised how easy and relatively pain-free the procedure was.

Hanging skin on the face is discussed in more detail in other sections but in brief may be:

• Excess brow skin that can be removed with a small incision at the hairline, inside the hairline, or at the eyebrow if there are wrinkles there. Please see the section on Expressive Brows.
• Upper eyelids hanging down - we do recommend an eye exam before eyelid surgery - and upper eyelid surgeries are sometimes covered by insurance. Check with your plan to see if it is a covered benefit. The skin is simple to resect but the incision does need to be made carefully in order to hide it well in the creases (not too high or too low), and sometimes tightening or trimming of underlying structures is needed which can increase the complexity of the case (but still be done with numbing medicine). Please see the website section on Looking at Eyes for more information.
• Lower eyelids can be done awake if it's just a little skin that needs to be excised - we use an incision right next to the eyelashes to hide it. If there is more complex work required, such as rearranging fat bags to address a groove between the eyelids and cheeks, it may require general anesthesia. Please see the section on Looking at Eyes for more information.
• A "hanging columella" of the nose can be addressed with nasal surgery - please see the website section on Shapely Nose.
• Cheek jowling and loose neck skin can be lifted and tightened or trimmed away. For more information on these, please see the website sections on Snatched Jawline, Lifting Your Face, and Facial Balance: Tox, Fillers & Threads.

Hanging of the breasts is addressed in the section on Breast Reshaping for ladies and Male Breast Gynecomastia for the gentlemen.

This section however is where we explore tummy tucks (abdominoplasty), arm lifts (brachioplasty), thigh lifts, back lifts, extended body lifts, .... Buttock lifts have their own website section called Buttock Enhancement.

Tummy tucks vary from a little skin excision to full on extended abdominoplasties that wraps around the sides of the body and include tightening of the muscle "fascia" to cinch in maximally. If you just have a little hanging pouch and there isn't looseness of the skin above the belly button (umbilicus), then a simple skin only excision will serve you well. We typically do not leave a drain for these and they can be done at the same times as other procedures such as liposuction, or by itself as an awake procedure.

The most commonly done tummy tuck at Pulsar Health, is where we do move the belly button, because otherwise it would be sitting too low or would still have looseness of the skin above it. This is called "umbilical transposition" and we remove a lot of skin / underlying fatty tissue with this procedure. It gives a much tighter abdomen. The length of the incision has to be long enough to remove all the extra skin, but we hide it in the panty line crease as much as possible. If you have loose skin on the sides of the body, you may need an extended abdominoplasty, where the incision wraps around the sides as well as front of the body, so that we can pull down the excess skin at the sides, better defining your waist. 

All of these procedures can be done "awake" but only a liter of fat can be removed by liposuction at the same procedure, so you may need to separate out procedures, called "staging". Also, we watch how much numbing medicine we can safely administer, so we may recommend staging if that is a concern too. With awake abdominoplasties, the risks are much lower than traditional abdominoplasties in terms of blood clots or more serious complications, and your recovery is faster without general anesthesia. We do recommend use of a pain medication called Experal at the time of surgery that is injected into your tissues, as it keeps you very comfortable for the first couple of days and greatly cuts down on using opiate painkillers.

The full traditional abdominoplasty removes skin and moves the belly button, but additionally there is tightening of the fascia, which is the lining of the rectus muscle and midline of the abdomen. This is helpful in those who have looseness of the fascia such as from childbirth, or who are trying to maximally cinch in their waistlines. It is a more uncomfortable procedure to recover from, and use of Experal medication is strongly recommended here. Currently we only do this procedure under general anesthesia.

After the tummy tuck surgery, expect to take a week or two off work after a tummy tuck, depending on your work. For any tummy tuck larger than a simple skin excision, we do use drains and encourage the use of garments, as we may do some liposuction at the same time. We cannot extensively liposuction your back at the same time as a tummy tuck, because that can interfere with proper skin healing. 

Other excision surgeries that we are frequently asked about are arm lifts and thigh lifts. 

A "short scar arm lift" has the incision placed in the crease of the armpit, whilst a traditional arm lift (brachioplasty) has a longer incision going down the length of the upper arm to the elbow, or rarely even beyond the elbow. Arm lifts may require extension of the scar across the armpit crease, which should not be a straight line as that can lead to constriction of arm movements. As these scars are amongst the most problematic in plastic surgery in terms of healing with thickening and / or widening, a short scar is preferable but only if it will remove adequate hanging skin, which is determined by how much hanging skin you have. We can advise you at your consultation. Sometimes there is fat as well as skin excess, so liposuction may be something of interest to you. Smaller surgeries can be done awake but general anesthesia is usually the better option for larger limbs or extensive excisions.

Similar to the short scar arm lift, the "short scar thigh lift" has the incision placed in the groin crease, whilst a traditional thigh lift also has the incision go down the inner side of the thigh to the knee, or sometimes even beyond for an extended thigh lift. A circumferential thigh lift may be needed, where skin is also taken from the back of the thigh. At Pulsar Health, we prefer to place the incision at the back underneath rather than over the top of the buttocks, to avoid flattening the buttocks. The inner thigh incision in a circumferential thigh lift does go all the way up the groin crease and wraps around the sides of the thighs to the buttocks. In thigh lifts there is a risk of widening the pubic area soft tissue by the way the scars heal, so we attempt to minimize this by anchoring the lift to the deeper tissues. After surgery, we work with you to minimize scar spread and may need to use steroids and lasers to improve healing, as well as possibly radiofrequency microneedling. Please see the section on Wounds, Scars and surgery for Moh's for more details on scar management.

Depending on where the excess skin is and how much, you may require other areas of skin excision such as a back lift or removal of the lump of skin and soft tissue between the armpit and breast, which can be accessory breast tissue. Where possible, we try to place incisions in prior creases or as in the axillary lumps, close to the armpit. Pressure from dressings / garments and reduced movement of the area are important to avoid a fluid accumulation after surgery in that area, and drains may be necessary. 

Overall complications of skin excision surgeries include bleeding, infection and scars as in most surgeries, but they are more likely to have fluid accumulation called a seroma, which is why we often leave drains in. A drain is a plastic tube that links the inside with the outside, and suction is applied by way of a bulb outside that looks like a little grenade. Your caregiver is taught how to "strip" the drain, empty it and measure how much is coming out, so that we can remove the drain when the amount is less than around 30cc/day. Applying appropriate pressure with dressings and garments, as well as reducing activity in that area, all help avoid fluid build up and allow us to remove drains sooner.

Another risk of skin excision surgeries is survival of the skin. We ask that you stop all nicotine exposure for three months prior and at least two months after surgeries that excise a significant amount of skin, to avoid complications such as infections or death of the skin. Surgery is not without risks, and we want to minimize these to get you the result you are looking for as safely and aesthetically pleasingly as possible.