This 34-year-old underwent surgery to shed 50kg but then comes a new problem: 6kg of drooping skin

SINGAPORE — When Mr Bernard Sim shed a third of his 160kg frame within a year after bariatric surgery, he was thrilled and for the first time, experienced what it was like to be able to move “quickly” when he returns to his walk-up apartment.

Growing up as “that fat kid”, he had problems losing weight and developed low self-esteem. 

By age 15, he was morbidly obese, which meant that he had a body mass index of above 37.4. 

A normal body mass index is between 18.5 and 22.9.

Mr Sim, now 34 and working as a programme manager at a bank, knew that it was only a matter of time before obesity led to medical problems. 

“You don't need a crystal ball to foresee that by my mid-30s, I would probably would have developed a chronic condition,” he said. 

He tried dieting and exercising, but losing a large amount of weight to attain a healthy weight felt impossible.

“Most people struggle to lose even 1kg to 2kg. What more someone who needs to lose 20kg and more?” 

In late 2020, he consulted a doctor at a polyclinic and was referred to the Switch team at Sengkang General Hospital (SKH), where he underwent a sleeve gastrectomy. 

This is a type of weight loss surgery that removes a portion of the stomach to make it smaller. There are two common types of bariatric surgery and Mr Sim chose sleeve gastrectomy.

Switch, which stands for Sengkang Weight Improvement Therapy and Complete Health, uses an evidence-based weight loss programme to help people lose and maintain weight in the long term. 

The surgery was a success, but as the kilos melted away, Mr Sim faced a new problem: Excessive skin folds that interfered with his self-confidence and quality of life.

Describing the skin folds as “overhanging off the belly” and “drooping down towards the groin area”, Mr Sim said that they made him feel self-conscious.

There was also the matter of hygiene and a risk of skin infection due to the skin rubbing, friction, moisture trapped in between the folds and rashes that can happen.

“Going out on a hot day, I’ll be drenched in my own perspiration in 15 minutes or fewer. Naturally, there will be some odour. 

“And if it wasn’t pleasant for me, it wasn’t pleasant for anyone,” he said.

Despite having lost 50kg to 60kg of body weight, he still mostly avoided activities that required him to remove his shirt, such as swimming. “I could (go swimming) perhaps, but it’d be unsightly for others.”

After consulting the Switch team, Mr Sim decided to undergo another surgery in 2021 — this time, to remove the excess skin. 

Around 6kg of excess skin consisting of skin tissue was removed in a type of body contouring surgery known as a circumferential belt lipectomy. 

During the surgery, excess pannus — the area of skin and fat that hangs over the pubic region — was removed around the entire circumference of the body. 

Dr Kok Yee Onn, a consultant with the plastics, reconstructive and aesthetics service at SKH who performed the surgery on Mr Sim, said that the remaining skin was “pulled down to meet the groin along the underwear line”, so that the scar is concealed. 

Recognising that some people may think that these surgeries were the “quick and easy way out” to lose weight and excess skin, Mr Sim — who now weighs about 90kg — told of the determination required. 

“It took me a lot of resolve, pain and discomfort to get to this point,” he said of the two years from the time he underwent bariatric surgery, then body contouring surgery and recovery. 

“But it's worth it, and I encourage those who recognise that they cannot (lose weight) on their own to explore this avenue with their doctors. 

“You don't need to be held back by your frame, by how you look.”

WHAT BODY CONTOURING SURGERY INVOLVES

The Switch programme at SKH adopts a multidisciplinary-team approach to help patients lose weight and maintain a healthy weight. 

Bariatric surgery and post-bariatric body contouring surgery are among its clinical services. 

It is estimated that more than half of the patients who had bariatric surgery at SKH underwent body contouring surgery or were interested in body contouring surgery, though the hospital did not give the exact numbers when asked.

In addition to younger patients, the team has seen more older patients in their 50s and 60s seeking to be “healthier and more active”, Dr Kok said. 

Bariatric surgery is surgery that achieves weight loss by restricting the amount of food the stomach can hold. Patients typically spend two to three days in the hospital and are ready to return to work within three to four weeks, SKH states on its website. 

As with any surgery, there may be potential risks as well, such as bleeding, leaks and infection.

As for body contouring surgery, one private doctor said that she performs one to three a month. Dr Lee Hanjing, visiting consultant and plastic surgeon at PanAsia Surgery, said that the ages of most patients ranged from their 20s to 50s. 

A common misconception about body contouring surgery is that it is a cosmetic procedure, but there are medical reasons involved. 

Dr Kok from SKH explained that body contouring surgery is “a medical procedure that is aimed at improving a person’s health and function”. 

Typically, it involves removing excess skin and fat from various parts of the body such as the abdomen, thigh and chest. 

It is done through a series of incisions or liposuction, followed by reshaping and tightening of the remaining tissues. 

Dr Kok said that doctors may recommend body contouring surgery after bariatric surgery, depending on individual circumstances. 

“Unlike cosmetic procedures like tummy tucks, where patients are well and desire enhancement of a normal body, body contouring offers more than just aesthetic benefits,” he added.

He also said that the decision to undergo body contouring surgery is “highly personal” and should be discussed with a plastic surgeon.

Another thing to note is that not everyone is suitable for body contouring surgery. 

Patients with significant medical issues (such as severe ischemic heart disease) or unstable weight may be considered unsuitable candidates, Dr Kok said. 

“Those with unstable weight are not suitable as they may end up gaining weight after body contouring surgery and waste the efforts of having gone through it.” 

WHY EXCESSIVE SKIN FOLDS APPEAR AFTER DRASTIC WEIGHT LOSS

Dr Lee from PanAsia Surgery explained that following massive weight loss, the soft tissues of the body (underlying skin and fat) deflate as weight is shed. 

Typically, the amount of weight loss after bariatric surgery tends to be greater than that achieved through natural weight loss.

“The skin that had been previously stretched out would now appear as loose skin with folds, because the quality of the skin following massive weight loss or bariatric surgery has poorer elasticity,” she said. 

Dr Kok highlighted that excess skin after drastic weight loss can interfere with daily activities, cause discomfort and affect the person’s self-esteem. 

It is also an obstacle to keeping good hygiene since cleaning between skin folds can be hard.

“For some people, it significantly affects their mental health and causes low mood and even depression. 

“In severe cases, the large skin folds may cause mobility issues, increase the risk of infections and cause wounds with repeated hospital admissions," he added. 

Dr Lee said that “it is not possible” to prevent excess skin after drastic weight loss, and the best way to manage it is to surgically remove it.

“The excess skin is a result of the weight and stretch from when the patient was at his maximum weight. 

“When the soft tissues deflate following weight loss, the surface area of the excess skin is generally still the same as before,” she explained. 

Dr Kok pointed out that although toning exercises may improve muscle tone, they cannot effectively address excess skin after significant weight loss, which often requires surgical intervention. 

“The best-case scenario… is the body naturally adapting over time with some minor skin contraction, but not to the extent achieved by surgery,” he said. 

HOW BODY CONTOURING SURGERY IMPROVES HEALTH

Dr Kok said that about four in five patients who have undergone bariatric surgery desire body contouring surgery.

Besides improving confidence and psychological well-being, studies in American and Asian medical journals have shown that patients who had body contouring surgery after bariatric surgery experienced significant improvements in physical function and quality of life, Dr Lee added. 

For instance, a pilot study published in 2023 in the Biomolecules and Biomedicine medical journal found that body contouring surgery led to short-term improvements in insulin resistance.

Those who had weight loss surgery also had better long-term blood sugar control and were less likely to experience severe blood sugar spikes compared to those who did not.

Even after a person loses a lot of weight, fat may remain under the skin. 

Dr Kok said: “Body contouring can also improve the patient’s chronic conditions like diabetes and hypertension by removing fat, which is a metabolic burden. 

“In some cases, patients have been cured of their diabetes and hypertension after undergoing bariatric surgery and body contouring surgery.” 

Dr Ben Ng, an endocrinologist at Arden Endocrinology Specialist Clinic, said it is important to be aware that body contouring procedures are “not a treatment for obesity, and not a weight-loss method”, although fatty tissue is removed from certain parts of the body during the procedure. 

Although there are several studies looking at the potential metabolic improvements using body contouring surgery, the evidence is “limited at present”, Dr Ng noted.

“Currently, metabolic surgery such as the gastric sleeve that targets visceral obesity (fat around the internal organs) are showing the best clinical benefit. 

“Procedures such as body sculpturing may help, but definitive scientific data on the benefits of these procedures are still lacking.” 

Dr Ng explained that when a person gains weight, each fat cell increases in size. 

“During liposuction, for example, the fat cells in a specific area are permanently removed and this alters the shape of the body. 

“However, if the patient does not maintain a healthy lifestyle, the remaining fat cells will grow bigger,” he said.

Body contouring procedures remove subcutaneous fat, which is the fat just under the skin, and not visceral fat. Visceral fat has been shown to be associated with an increased risk of heart disease, diabetes and high blood pressure. 

That said, body contouring procedures can potentially help from a psychological perspective and motivate individuals to want to exercise more, Dr Ng said.  

“For health benefits and improvements to chronic conditions such as diabetes and heart disease, it important to consider more evidence-based procedures such as metabolic surgery. 

“I would encourage all patients desiring weight loss to discuss in greater detail with their doctors,” he added.  

Dr Lee from PanAsia Surgery observed that patients generally feel more confident after body contour surgery, which improves their emotional and mental well-being as well as motivation to keep fit. 

WHAT RECOVERY PERIOD IS LIKE AFTER SURGERY

After body contouring surgery, Mr Sim found that managing the drains and negative-pressure wound therapy machines attached to his body was the most challenging part of his recovery. 

After the surgery, surgical drain tubes, compression garments and supportive pressure support devices are usually used to enhance recovery, Dr Lee said. 

Mr Sim had about two negative-pressure machines and four surgical drain tubes attached to his body immediately after the surgery to remove excess fluid and promote healing. 

“I had to sleep with the surgical drains as well. There were occasions when I found myself just bound up right in the middle of the night and had to untangle myself. 

“Going out with a hospital bag and tubes sticking out my body also led to some uninvited attention,” he recalled. 

After the surgery, he was in the hospital for about six days. About three days after he was discharged, he was re-admitted to the hospital for a wound infection.

The attachments finally came off about two months after surgery.

Dr Kok said that the scars usually heal in two to four weeks, and patients can be back to doing physical activities a month or two after that.

In the first few months after scars heal, however, exercises that cause excessive skin tension such as sit-ups must be avoided. 

Moderate activities such as jogging can start from the second month after scars heal; more intensive exercises usually from the third month. 

HOW MUCH DOES BODY CONTOURING SURGERY COST

Dr Lee from PanAsia Surgery said that the cost depends on factors such as the areas being done on the body.

Several areas can be combined in the same surgical setting. If multiple areas are bothering the patient, the surgery may be split into different operations. 

The amount of excess skin removed also varies. 

Body contouring surgery following bariatric surgery is subsidised at public hospitals because it leads to health improvements in chronic disease, confidence and function, Dr Kok from SKH said. 

It can also be claimed using the patient’s Central Provident Fund Medisave account. 

Mr Sim estimated that he paid around S$4,000 for the bariatric surgery and body contouring procedure after subsidies. He stayed in a Class C or six-bedder ward. 

DIFFERENCES BEFORE AND AFTER WEIGHT LOSS AND SURGERY

The drastic weight loss and extensive body contouring surgery have been life-changing for Mr Sim. 

Recalling how he used to “stick out like a sore thumb” everywhere he went because of his weight, he said: “Living in Asia where most people have a smaller frame, it completely pulverised my self-confidence. 

“You go on a bus and you’re not able to share seats with people. 

“Your size is the first impression that people have of you, so right at the onset, everyone just knows you as ‘that fat kid’ — and that becomes your complete identity.”

He would frequently get unwanted questions about his weight. 

“Out of nowhere, I would have people asking, ‘Have you thought of losing weight?’ or saying, ‘If you lose weight, you’ll be very handsome’. 

“It got to a point where I would expect these comments all the time. 

“I just carried on with life — not that it didn’t hurt,” he said. 

In social and professional settings, Mr Sim felt that he was often overlooked when he was at his heaviest. 

“I noticed that I wasn’t as ‘seen’ or ‘heard’ when I was at my heftiest — ironic. 

“I think there was a pre-judgement, that maybe bigger-sized guys don’t really know their stuff,” he added. 

“Whereas today, I notice that people and colleagues are more likely to want to get into conversations with me and understand my thoughts, whether it's seeking out my opinion or clarifications.” 

Besides having newfound confidence, Mr Sim also appreciates being fitter and more mobile.  

“I live in a walk-up apartment and now, I can get from the ground floor to my unit really quickly — that’s something I’ve never experienced before. 

“Previously, I will probably have to take breaks, struggle a lot. Getting onto airplane, sharing seats and sitting next to people, I don’t feel as self-conscious anymore.

“Being able to be myself and not get pre-judged based on how I look is probably the icing on the cake.”