These Photos Show The Problem With Excess Skin After Extreme Weight Loss

By the time Tatiana Bobbitt lost 190 pounds, she knew she had a problem. It had been 21 months since her successful bariatric surgery, and while she had shed nearly 200 pounds from her 5’11”, 450-pound frame, her body was covered with loose, stretched-out skin.

Bobbitt put on the weight in adolescence and now credits her gain to the fallout from her sexual assault — the stress of keeping a painful secret, as well as the side effects from different depression medications and mood stabilizers. These caused her to balloon to 275 pounds by the time she was 16 years old. At 19, she was diagnosed with rheumatoid arthritis, which made it even more difficult for Bobbitt to work out. By 24, she was over 425 pounds. She decided to get the surgery, she wrote in a Reddit post, because “I’d lost all hope of ever getting myself back.”

But Bobbitt’s self-image took a dive because of the way her post-weight loss body looked; While she said she should have been enjoying her newfound mobility and health, Bobbitt found herself agonizing over the appearance of her extra skin.

“I was seeing my body morph into a blob of extra skin,” Bobbitt told The Huffington Post. “I finally had a shape, my joint pain was more bearable [and] I wasn’t squeezing into booths anymore or turning sideways to fit through spaces I previously couldn’t. [But] I traded one insecurity (being morbidly obese and fat) for another (having pounds of loose skin).”

“I couldn’t see the weight loss anymore — just skin.”

For almost anyone, achieving necessary weight loss would be unequivocally celebrated and cheered. But for people like Bobbitt, who lose an extreme amount of weight, the achievement can bring with it a new set of physical and psychological problems. And nowhere is that more true than when it comes to skin. In Bobbitt’s case, it hung down low over her waist and past her groin. It weighed down her arms with large flaps. It caused pain, frequent infections and put her at risk of necrosis of the skin, which is when cells die and essentially rot while embedded in living tissue.

“I felt gross when I saw myself naked and when it came to dating, it was a big insecurity,” Bobbitt described. “I also lost motivation because I just couldn’t see the weight loss anymore — just skin.”

Excess skin is complicated to care for: there’s cleaning it between the skin folds to prevent infection and painful rashes, strategic clothing to mask its presence and the shame and distress of, once again, feeling uncomfortable in one’s own body. But despite complications both medical and psychological, many insurance companies don’t cover skin removal.

Tatiana Bobbitt’s midsection after extreme weight loss, then three weeks and five months after her excess skin removal surgery.

More Than Cosmetic

Insurance companies commonly regard excess skin surgery as an elective, cosmetic issue and thus not worthy of coverage, which makes the surgery out of reach for thousands who may want or need it.

Last year, almost 45,000 Americans went under the knife to re-contour their bodies after massive weight loss, according to statistics from the American Society of Plastic Surgeons. And the number of these surgeries, like thigh lifts, upper arm lifts, tummy tucks and breast lifts, grew at its fastest rate in four years. But this represents only a fraction of the approximately 179,000 Americans who get bariatric surgery every year and could conceivably have lost enough weight to warrant excess skin removal.

Even with health insurance approval, many find that their coverage is incomplete. Commonly, according to plastic surgeon according to Dr. Jeffrey Gusenoff, only belly skin removal, which has the highest rate of infection, is covered. And first the patient has to prove that he absolutely needs the operation. That means enduring and documenting several months of skin rashes, explained Gusenoff, who is also an associate of plastic surgery at the University of Pittburgh Medical Center. While painful, delaying the surgery in order to get documentation for insurance companies is usually worth it, as every little bit of coverage counts, said Gusenoff.

When Bobbitt’s doctor told her she was in danger of necrosis of the skin, she knew she couldn’t delay the skin surgery to reach her “goal weight” any longer. However, she didn’t have health insurance at the time, and her parents’ policy wouldn’t have covered the operations, she said. But once her parents saw the extent of her infections, as well as the extreme amount of skin she was hiding underneath her clothes, they decided to foot the bill for the trio of surgeries she needed: a corset trunkplasty to tighten the abdomen, a brachioplasty for arms and a mons lift to address the skin above her pubis.

In this pre-operation photo, Bobbitt shows how different her body looks, with and without clothes.

To finance the operations, they put up around $10,000 and got financing for the rest of the $22,000 bill, and in January 2013, Bobbitt got all three procedures done on one day. Doctors told her mother that they had removed 12 pounds of excess skin from Bobbitt’s body. She sustained nerve damage from the surgeries, as well as an abdominal abscess that had formed as the result of a surgery complication. But despite the enormous costs, as well as months of excruciating recovery, Bobbitt says she is one of the lucky ones.

The ‘Slippery Slope’ Of Insurance Coverage

Weight loss surgery itself wasn’t considered medically necessary until scientists began proving that the operation also seemed to cure type 2 diabetes and hypertension, in addition to obesity. The tide began to turn in 2006, when the Centers for Medicaid and Medicare Services decided to approve bariatric surgery for Medicare patients with a body mass index over 35 and at least one additional health complication related to obesity, according to the Obesity Action Coalition.

“It took a long time for the medical community and insurance companies to regard obesity as a disease process,” said plastic surgeon Dr. Scot Glasberg (who is also the president of ASPS). “Now, there needs to be an understanding that these patients need to be covered throughout their continuum of care.”

Dr. Eric Volckmann, director of Bariatric Surgery at University of Utah and a practicing surgeon, agrees with the need for more insurance companies to cover excess skin removals. “It’s very problematic for patients — particularly the ones who have done the best and have lost the most weight and are the most physical active,” said Volckmann in a phone call with HuffPost. “They’re often in the greatest need of removal of that skin.”

“It’s very problematic for patients — particularly the ones who have done the best and have lost the most weight and are the most physical active.”

Until things change, Gusenoff and Volckmann agree that part of preparing their patients for weight loss surgery is making sure they know about the potential need for skin contouring surgery — including the costs and additional recovery time. “We do try to go to bat for our patients and try to get insurance coverage, because that could help make these cosmetic procedures more affordable for them,” Gusenoff told HuffPost.

But while he empathizes with his patients, Gusenoff understands that covering plastic surgery can become a “slippery slope” for insurance companies. For instance, he pointed out, there’s a difference between a breast reduction, which removes mass from the breast, and a breast lift, which gives breasts a more youthful appearance. It’s not clear where the line is between medical necessity and cosmetic enhancement, he explained.

The Psychological Weight Of Excess Skin

There isn’t much research on the psychological effects that extreme weight loss can have on people. But one small 2014 study that interviewed 11 women after their surgeries found that, despite all the positives that came with their weight loss, a common complaint was the amount of excess skin they were left with after reaching their goal weight. Many, but not all of the women, described the excess skin as distressing and felt self-conscious when naked with a sexual partner. Like Bobbitt, they also faced constant fungal and bacterial infections that developed between the folds of their skin. However, none of the women’s insurance policies would cover the “cosmetic” skin removal surgery.

“None of them said they wouldn’t do [weight loss surgery] again,” the study’s researcher Christine Aramburu Alegria, an associate professor at the Orvis School of Nursing, told HuffPost. “However, prominent in the interviews were some of the negative self-views that come with losing a lot of weight pretty rapidly.”

Thanks to her skin removal surgery, Bobbitt doesn’t face those kinds of problems. Two years after the surgeries, 28-year-old Bobbitt is happy, healthy and maintaining a 210-pound weight loss in Brenham, Texas. Her joints are less strained, which makes it easier to manage her rheumatoid arthritis, and she has more energy. After graduating from college in Dec. 2014 (something she says wouldn’t have been possible before her weight loss journey), she got married to a man she met while she was in the midst of her skin operations. She now sports “bad ass” surgery scars and is proud of regaining her health and a new life. In many ways, Bobbitt got the fairytale ending.

Tatiana Bobbitt tries on a wedding dress in the months before her wedding.

But Bobbitt’s story isn’t typical. Many more post-bariatric surgery patients like Volckmann’s clients or the women in the study have to make do with their new reality, skin flaps and all. Bobbitt wishes that there were more financially viable options for people like her, but also hopes that the inevitability of excess skin doesn’t deter anyone from trying to get to a healthy weight.

“Lose the weight regardless of any reservations you have about possibly hating your body even more just because of loose skin,” she said. “It really is worth it in the long run.” But at the same time, she acknowledges that the excess skin surgery changed her life for the better, just as her weight loss operation did.

“If I hadn’t been able to get these surgeries thanks to my parents, I really don’t know what I would have done,” said Bobbitt. “I’d probably be in ridiculous debt due to hospital bills and uninsured surgeries that would’ve just removed the infected skin. I think I would regret ever losing the weight in the first place.”