What Happens to Your Skin After GLP-1 Weight Loss

Kirstin:
00:01 - 00:12
You're listening to Alabama the Beautiful. I'm Kirstin Jarvis and I'm here with Alabama cosmetic surgeons Dr. James Koehler and Dr. Vincent Gardner. Hey, Dr. Gardner, Dr. Koehler.

Dr. Gardner:
00:13 - 00:13
Hey, Kirstin.

Dr. Koehler:
00:14 - 00:15
Hello, hello.

Kirstin:
00:15 - 00:27
Today we're going to talk about GLP-1s. We know that GLP-1s are taking weight off people faster than the skin can keep up. But what's actually showing up here in the office that wasn't showing up a year ago?

Dr. Gardner:
00:28 - 02:28
We're seeing lots and lots of people that are, I would say, some of them are a combination, meaning they had a Roux-en-Y years ago. They lost significant weight, but they slowly gained it back over time. And then they were prescribed the GLP-1s, Wegovy, Ozempic, and now they have been able to kind of reinvigorate their weight loss. And so they've lost significant weight. And I've seen plenty of people who are now simply GLP-1-related weight loss. And we have patients that have lost, gosh, 80, 100. I saw a lady today who lost 160 pounds. We're going to do skin removal surgery on her. And one of her biggest concerns is, when am I going to get to start my GLP-1 post-op? Because she's so terrified of regaining weight. And I think that can be a legitimate concern. But I think, you know, like a gastric procedure, a sleeve or Roux-en-Y, we would always preach that those are tools to help you kind of change your relationship with food. And so like a gastric procedure, I think GLP-1 is a similar thing in that it's to try to help you change your relationship with food. And hopefully with that, they can be successful. Now, the drug companies would like patients to stay on these medications indefinitely, you know, for a lifetime. But I would argue that, hey, if you're successful, I think it's okay to start to try to wean back your dose, maybe even wean back completely off the medication. But you have to, you know, be able to maintain your weight loss. Otherwise, you're going to jeopardize your health as well as your cosmetic result. Because if we do a nice surgery, a tummy tuck, a breast surgery, and then somebody regains 40, 50 pounds, their results are going to be different.

Kirstin:
02:29 - 02:39
How do GLP-1 results show up differently than gastric bypass results when you're examining someone for surgery? Like, for example, skin quality, is it different between the two?

Dr. Gardner:
02:40 - 07:36
I don't know. That's a great question. And I think you can have people argue either side of that. I think, well, I will tell you, if you look at studies where people have fasted to lose their weight and, you know, when you say that fasting is something that a lot of people say they do, they do intermittent fasting. And there's a lot of, I think, data to help support this, that patients can be really successful because what you're doing with intermittent fasting is it takes about 12 hours to burn up your glycogen stores in your liver and your muscle. And so once you hit that 12-hour mark, those stores are gone. And that's when you start to switch into a fat-burning mode. And so the goal of intermittent fasting is to keep you from eating for more than 12 hours. Specifically, every hour you go after 12 hours, you're starting to burn fat. So if you can go 14 hours, 16 hours, 18 hours, then you're going to have much more significant weight loss because you're able to burn fat more readily. And some people will do intermittent fasting every day. Some people will do it for five days and take the weekend off. Any kind of scenario you want, you can do. So I think that with fasting, a lot of people tend to lose weight, but they tend to do it a little more slowly. And I was listening to someone talk, and I can't remember all the details, but it was somebody who's an expert in fasting. But I'm talking about long-term fasting where you have people that will go for 10, 20, 30, 40 days because they're losing a really huge amount. But these are medically supervised. And there are a lot of places in Europe where you can go and they have hospitals that are essentially fasting hospitals where they're monitoring electrolytes, they're monitoring your water intake, and they're doing it in a very systematic fashion. But I once heard somebody say that he had a patient that lost 200 pounds and had almost no redundant skin. And it's because the weight loss was gradual, very slow, and the skin retracted beautifully. And he said in his opinion, through his experience, that he felt like patients that lost weight in a fasting type mode where they're going long term with just water and electrolytes did really well and said felt like their skin retracted much more readily as opposed to people who tend to lose weight fast with some of these medications. And we see it all the time. They have poor skin quality. And the frustration is, and I tell every patient this, I like, hey, I'm going to pull your, if we say we're doing a tummy tuck, I'm going to pull your tummy as tight as I possibly knowing that no matter how tight I pull it, you're going to have some skin laxity develop over the next probably three to six months, maybe a year. And it's super frustrating because some of these patients get really irritated. And I say, look, I can't fix your skin quality. All I can do is pull it as tight as I can that's safe. And then we have to kind of see where things land and possibly they may need a little revision, meaning a little more tissue pulled out later. But remember, it's the quality of skin that we're removing, not the amount. And so it's a frustrating thing to fight. Well, Dr. Gardner, don't you think when you make an incision on somebody who's, let's say, had a Roux-en-Y gastric bypass, like that skin, when you cut into it, is different than somebody who, let's say, lost it on maybe GLP-1s? It may be. I mean, I think there's an argument that people that lose it on GLP-1s have a much thinner skin and they just don't do as well. but I don't know the answer. When I see these Roux-en-Y patients, like I feel like they have really thin skin. I mean, they're in a constant state of, you know, malnutrition, you know, and their dermis seems thinner. I don't know. Definitely weight loss patients as a whole, if it doesn't matter what the method is, I kind of feel like the thickness of the dermis and, you know, it's just, and the skin quality in general is just different. I don't know. And it's just subjective. That's just my opinion. Well, I mean, you bring up a good point and I don't know that I know the difference anymore. And I will tell you why, because the weight loss that we see is so varied. Like I said, we see some people that have had gastric bypass or a sleeve and they lost the first hundred pounds that way. And then the last 50, they lost with a GLP-1. So I agree with you. It's poor skin quality all the way around. And when you have a lot of stretch marks, that's where the dermis has actually been pulled apart. And so you get really thin epidermis with very little or an attenuated dermis below it. And it doesn't hold sutures well, and it just tends to scar poorly. And it long-term can stretch, and they can have issues with laxity. But I tell everybody that up front, that, hey, I'm going to pull it as tight as I can safely, and you may have some laxity afterwards.

Kirstin:
07:37 - 07:47
Let's talk a little bit more about loose skin. Everyone talks about ozempic face. But on the body, where is loose skin showing up the most?

Dr. Gardner:
07:48 - 08:02
Well, I mean, now there's ozempic everything, right? You can have ozempic face. They're talking about ozempic belly, ozempic butt, ozempic arm. I mean, obviously, just put it in front of whatever body part you want.

Kirstin:
08:02 - 08:02
Yeah.

Dr. Gardner:
08:03 - 08:46
I think the main areas that we see really a lot of laxity, obviously, is the belly. And I think that all goes back to, were you an apple or were you a pear when you had your extra weight? Because if you've lost 100 pounds and you carried the primary amount of that in your belly and you had really thin legs but just a big belly, then your abdomen skin is going to be super stretched out and very poor quality. Whereas if you're a pear and your waist is fairly small but you've got really big hips, thighs, and buttocks, then you're going to have stretched out skin in that area. And then there's a combination where you have a big belly and you're kind of a pear apple combo. So it really just depends. Fruit salad. Yeah, exactly.

Kirstin:
08:47 - 08:55
Are you seeing things in places where people don't expect, like their knees, thighs, breasts, things like that?

Dr. Gardner:
08:55 - 10:00
Yeah. I mean, I think they may be shocked. I don't think we're shocked. I mean, because we see it every day. But, you know, when you're at home and you're really just looking at yourself in the mirror, you may be surprised, but we're not surprised because we see everything that walks in the door. But, you know, some people do. And I have the frustration. Let's talk about a thigh lift for a second. One of the big frustrations is I hate my thighs. Well, there's different kinds of thighs. There are some people that still have, even though they've lost 150 pounds, they still carry a lot of weight in their thighs. And that's just because that's the way they were born. That's their genetics. Their belly's really thin, but they still have this extra weight. So you can do a thigh lift on them, but they have to know that, you know, we're still probably going to have issues with thighs afterwards. Whereas some people, if they carry their weight in their belly, their thighs, even after losing 150 pounds, they look really good. And maybe the upper one-third of their thigh doesn't look great, and we can do more of a limited thigh lift. But, again, it's all about your fat distribution, where you lose it, And I think how fast you lose it.

Kirstin:
10:01 - 10:21
So we've talked on our podcast before about how we really prefer not to operate on people who are in the middle of their weight loss journey. So say people, there's, you know, patients who've reached their goal. How soon should they contact you after, you know, they've met their goal weight and their weight has stabilized?

Dr. Gardner:
10:22 - 11:52
Yeah. So used to when I was doing gastric bypass, you know, 20 years ago, we would tell everybody, hey, you need to have lost your weight, kept it off for a year. And once you've proven over that year that you can keep it off, then you're a candidate. I don't think that's the case anymore. I think I do like to see some time frame where people have kept it off. And I would say six months is reasonable. And I'll tell you, I've seen people, I had a gentleman come see me years ago, and he had lost over 100 pounds, but he was still, his BMI was still like 45 or 50. And I said, look, you're doing a great job. And we talked to him about a tummy tuck, because that's all he wanted, because he had an abdominal pannus. His abdomen hung down so low that when he would walk, his knees would kick or hit the pannus. And he said, look, I'm just trying to get my walking in. And his thing was he was walking and eating fish and doing great. And so I saw him about a year after that. And his BMI was down in the mid-30s. And we ended up taking a 30-pound pannus off his abdomen. And that was the happiest guy you can imagine. And we did it because he was tired of kicking this thing. So yeah, I mean, I think there's all comers. And we don't discriminate. We take it all off.

Kirstin:
11:53 - 12:04
Is there a certain conversation you have or is it difficult to have the conversation when somebody is adamant that they want surgery now, but you know they've not reached their goal or they're not done losing weight yet?

Dr. Gardner:
12:04 - 12:44
Well, yeah. And I have that conversation because let's be realistic. There's plenty of people that they may say they've lost 100 pounds and they're at 150. And they're like, well, you know what? I'm going to lose 30 more pounds. Okay, great. are you really going to lose 30 more pounds? They may say they're going to lose 30 more pounds, but then I say, look, is that your realistic goal? And do you really think you're going to do that? If they tell me, absolutely, I'm going to do it, then I'm saying, okay, then we need to wait before we do your surgery. But if they're really honest and they say, yeah, maybe I'm going to lose 10 more, then I think it's reasonable. I think if you're within 10 to 15 pounds of your goal, then I think that's a reasonable place to be to go ahead and have skin removal surgery.

Kirstin:
12:46 - 13:03
So let's talk about reality checks. You mentioned that sometimes skin quality prevents you from getting the absolute best result the first time around. Are you ever telling people ahead of time that one surgery probably isn't going to be enough and that they're maybe looking at a longer journey?

Dr. Gardner:
13:04 - 14:47
Good question. I tell that, well, I don't specifically say, hey, you're going to need this. But I gave a talk at our meeting this year, and one of them was a secondary buttock augmentation. And so I've had multiple patients where we do an aggressive buttock lift with an auto augmentation to maintain their fullness. And they look fantastic for three to six months. And then they start to develop some laxity. And that has to do with more to do with inflammation going down, some swelling going down, plus the poor skin quality. And so I've had multiple patients where we will go back and take another 10 centimeters sometimes or more of skin on the buttocks because we've allowed it to loosen up and now it's a little bit mobile. And those patients are really happy because once we do it a second time, it tends to stay, meaning we don't tend to see the stretching out that we did after the first surgery. And again, I don't think it's necessarily stretching out. I think it's laxity and poor skin quality. It's not like what we did and they just stretched everything back out. But I do tell people that there are situations where they may need an additional procedure. And it's not going to be nearly as intense or in-depth or worrisome as the first one. But yeah, there's plenty of times where we can do that and really make somebody look better. But I think the majority of patients are going to have a great result with the initial surgery. But if there's somebody who's like, you know what, I hate this and I really want to do it, then yeah, we'll take some of those patients back.

Kirstin:
14:49 - 14:57
Where does non-surgical skin tightening fit for this specific group? Or is that kind of fake news for these patients?

Dr. Gardner:
14:57 - 15:51
I don't know. I'm not a huge fan of that. When you have really poor skin quality, I'm not saying that there aren't people out there that might get some results, but I'm pretty cautious about recommending that for a patient because the last thing we want to do is take somebody's money and know that they are not going to get a significant result. Now, what's significant? Well, that's up to the patient, but I've seen people that get 30% improvement and they're ecstatic, and I am too because 30% is a lot. But in somebody who's got poor skin quality from massive weight loss with stretch benchmarks and a thin dermis, I would not offer them that. Now, I'm not saying there's not some outside chance that somebody might get a result, but I'm not a super fan of trying to push that or use that as a first line or even a distant second line treatment.

Kirstin:
15:51 - 16:02
Yeah, it's kind of, you know, not everybody has a ton of disposable income. So when you spend thousands of dollars on a treatment and then you're unhappy with the results.

Dr. Gardner:
16:02 - 16:14
Yeah, your results are our reputation and we want you to have a great result. And that's what our goal is, is to give you a great result. And I just don't think it's there for non-invasive skin tightening.

Kirstin:
16:15 - 16:24
Okay, let's talk the long game. If someone goes off the medication and gains 20 pounds back, what does that do to their surgical results?

Dr. Gardner:
16:26 - 17:40
You know, again, like I said, I'll operate on somebody if they tell me they're within 10 to 15 pounds of their goal. So gaining 20 pounds to me is not that big a deal. And again, where are they going to regain? They may not regain that weight in an area that we've operated. So it may not affect their results at all. It really just depends because if we're doing lipo, now I would say a lot of these massive weight loss patients do need lipo and a lot of them don't. And liposuction, we're removing the fat storage area in the area that we're operating on or lipoing. And so a lot of times if they regain weight, they don't regain it there because we've removed a lot of those fat cells and they may regain weight somewhere else. So I think it just depends on the specific patient and, like you said, how much they gain. But I don't think 20 pounds is going to make a huge difference, but it can. And that's why we like to weigh people before we operate, because I don't ever want somebody to come back and say, hey, I'm unhappy with my result. And turns out we put them on the scale and it's like, oh my gosh, they've gained a lot of weight. So it can alter their results. But, you know, I think that as long as they're, you know, safe with it and they're trying to maintain their weight, I think they'll do fine.

Kirstin:
17:41 - 17:50
Does what you're doing in the operating room change if you know that your patient is going to be on a GLP-1 for long term?

Dr. Gardner:
17:50 - 19:30
No, not really. I mean, obviously the big thing about GLP-1s is they affect the GI tract. So we have them come off for two weeks prior to the procedure for safety concerns because part of the process or the, I guess, the way the drug works is slows the GI tract. And that slowed or delayed gastric emptying, when we go to intubate somebody, the last thing we want is a stomach full of gastric contents. And so, you know, if somebody hasn't been off their GLP-1s, we're very, you know, cautious about operating on them. So we require two weeks. but I'm not worried about people being on them long-term. You know, GLP-1s have been around for 15 years. It's not like we only have five years of data. We've got a lot of long-term data because it's been around for diabetes for a long time. But again, and these are marketed to be a lifelong medication. Although I think there's a significant interest in microdosing and maybe not using the highest doses. Now, if you can't lose weight and you need a higher dose, then you need a higher dose. But I would come off that higher dose and test some of the lower doses. Let's say you're really successful. Do you really need to stay at that higher dose? I would say let's try to back off the dose. And if you can maintain your weight loss on a much lesser dose, I think that's important because a lot of the people that microdose say that a lot of these side effects are because of the dosing of the drug. And the higher the dose, the more likely you are to have some side effects. And so anyway, I'm a proponent of lowest dose that's effective for these patients.

Kirstin:
19:31 - 19:41
So for someone still mid-loss or in the middle of their journey right now, wondering if they should be planning for surgery, what's the next move?

Dr. Gardner:
19:42 - 20:32
So I think it's reasonable to plan for your surgery. I mean, you've got to be positive about this. And I'm all about the positive mental attitude. and you're like, hey, I'm going to lose this weight. I'm going to have this tummy tuck, breast surgery, arm lift, whatever it is your goal is, stick with your goal. And you may not be there yet, but I mean, it's okay to go ahead and start researching that, finding what you want, find the before and after photo. That's why I encourage people, go to our website, go to our Instagram, go look at our work because that's, again, our results are our reputation And we want you to go look at our work so you can see what we think we can accomplish. But I think it's great for people to start dreaming and start mapping out their journey and sticking to it. Yes.

Kirstin:
20:33 - 20:43
Okay. Some people are saying that the GLP-1 area is going to bury cosmetic surgery, that everyone's just going to take a shot and skip the operating room. Is that true? Or nothing to that?

Dr. Gardner:
20:47 - 20:48
The opposite. Yeah,for massive weight loss, it's the opposite. Our office is going to fill up because, again, think about it. When you lose that much weight, unless your skin retracts and you're one of the few people that that really retracts really well, you're going to need something done. And unfortunately for, well, I said fortunately or unfortunately, it's job security for us. And what I mean by that is these patients unfortunately trade one problem for another. And we've seen this with bariatric surgery for years. Hey, I've lost all this weight. Now I can't go to the gym because my skin flaps all over the place. And I have people wear two or three Spanx to go to the gym to kind of hold everything in and they're not going to put up with that. So I wish that they didn't have excess skin, but they do. and that's not going to, I mean, I think the opposite of that's going to happen.

Kirstin:
21:44 - 21:49
I think that people saying that are the same ones that think liposuction is a weight loss cure.

Dr. Gardner:
21:51 - 21:51
Gosh, yeah. A lot of people think that, hey, I'm just going to have liposuction and I'm going to look great. And we have a lot of people that come in just for liposuction and I tell them, you know what, we're going to liposuction the skin off and then we need to do a tuck. And they look at me like I'm crazy and I tell them, look, we've done it time and time again. If you lipo all of the skin, unless you're 20, you know, being a little overly dramatic, but unless you have really good skin quality and you're on the younger side of the age scale, you're probably not going to have the skin retraction that you think you will. Now, I've been surprised and I've done some people that are older in life and they've had fantastic skin retraction, but just think about it. Our collagen and elastin as we age, they don't do that well. And so people tend to have more drooping and they just don't retract like we think they're going to. Now we can add heat to it, Renuvion, BodyTite, some of these modalities, and it can help. But I just think that a lot of these patients, once we do lipo, they need a tuck. And you're right. Liposuction does not equal weight loss. Liposuction equals fat removal. But if you keep eating the same and burning the same calories in and calories out, you're going to maintain your weight. It's just going to go somewhere else.

Kirstin:
23:10 - 23:10
Heard.

Dr. Gardner:
23:12 - 23:12
Preach.

Kirstin:
23:14 - 23:15
All right. Do you have anything to add?

Dr. Gardner:
23:16 - 23:33
We love weight loss patients, and that is one of our specialties. And skin removal after massive weight loss, some of the happiest patients. And I love my patients because they just tend to do well and they're happy and they're motivated. And so, yeah, we love them. Come see us.

Kirstin:
23:34 - 23:49
All right. Do you have a burning question for Dr. Koehler or Dr. Gardner or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler and Dr. Gardner. Go back to making Alabama beautiful.

Announcer:
23:52 - 24:34
Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S dot I-O.