You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird.... So let's look at the bird and see what it's doing that's what counts. I learned very early the difference between knowing the name of something and knowing something.
-Richard Feynman, physicist
It seems that after weight-loss surgery, the thing nearly everyone becomes concerned about is an organ most people take for granted. That is the skin. This chapter is devoted to helping you understand this often overlooked organ, so uniquely affected by weight gain and loss, so you can better care for it.
The first class you take in medical school is gross anatomy. That is the study of all the body parts, big, small, and in between. The study of anatomy involves learning how all the organs, blood vessels, nerves, and bones fit together in one nice, neat package. What is often overlooked is that the package is wrapped up inside a single remarkable organ we call skin.
In addition to being the largest organ of the body, the skin is also one of the most important. We tend to take the skin for granted, perhaps because we see it and touch it every day. All the other organs, with the exception of the eyes, are hidden and are therefore quite mysterious and seemingly more important.
Recently an art exhibit came through our city called "Body Worlds." You may have seen it. The exhibition consists of a collection of anatomy dissections, some of individual organs and several entire human bodies in various poses with the skin removed. The underlying muscles, bones, and internal organs are displayed in a fascinating and artistic manner for everyone to see.
The dissection of these bodies obviously occurred after the death of the individual, and the tissues have been preserved to avoid decay. Reactions to the exhibit range from awe to disgust, because these are parts of real bodies that most people have never seen. They are always covered with ordinary old skin. By showing these dissected specimens as if performing various activities such as playing basketball or riding a horse, the artist is attempting to show what the living body would look like without its outer covering. But the fact is that human life is not possible without the protection provided by the skin.
What Is Skin and What Does It Do?
The skin is a very complex organ that provides a number of vital functions. It is both flexible and extremely tough. It is waterproof and thoroughly washable, yet requires very little in the way of maintenance. It is one of our most important sensory organs, providing us with both pleasurable touch and pain that can trigger a reflex withdrawal away from harm. It is our primary protection against bacterial invasion and provides the most important mechanism for regulating our internal temperature. It replaces itself continuously and when injured is capable of regenerating itself automatically.
It grows with us from birth to adulthood. It can stretch to meet the needs of an enlarging body, as we've all seen with obesity or pregnancy, then more or less contract back to its original size. It can be transferred from one part of the body to another, and even from one body to another and survive and grow. We can and often do neglect it and even abuse it, but it continues to serve us in all of these ways. The skin is truly one of the most amazing organs of the body.
Skin is composed of two primary layers. The top or superficial layer is called the epidermis, which is continuously replaced. The second or deep layer, the dermis, remains more or less constant.
The layer of cells that separates these two layers is called the basal layer, and it is responsible for creating the epidermis by continuously producing new cells that are progressively pushed toward the surface. As the cells get closer to the surface they tend to flatten out and die. The top of the skin is actually layers of dead cells that eventually wear away, only to be replaced by the new ones making their way toward the surface.
Melanocytes are also located within the basal layer. These are the cells that produce the skin pigment melanin. The color of the skin, which can range from extremely pale yellow to almost black, is determined both by how many melanocytes are present and how active they are at producing pigment. Exposure to ultraviolet light will temporarily stimulate these cells to produce more melanin, a process commonly known as getting a tan.
Within the skin are a number of specialized structures, each of which has an important role to play in the overall function of this organ. The one that is most obvious is the hair follicle. Hair follicles are present to one degree or another in virtually every area of the skin, and each follicle gives rise to a single hair. Generally the follicles are most numerous and arranged very close together on the top of your head, but that obviously varies from person to person. Growing out of the follicle is a shaft of hair, which is composed of very strong but dead cellular material that is held together by filaments of protein called keratin. Hair comes in a variety of colors and textures, straight or curly, and is a major contributor to our personal appearance. But that is not its job.
The main function of your hair is to improve the insulating capability of the skin. Having a lot of hair on your head can serve you very well on a cold, wintry day, and it also helps cool your scalp if you're out in the blazing sun. Each little hair follicle has a tiny little muscle attached to it called a pilo-erector muscle. When you are cold or become frightened all those tiny muscles contract, making each hair stand straight up "a hair-raising experience." This automatic process actually serves to change the flow of air over the surface of the skin, which increases its insulating properties.
Another structure contained within the skin is the sebaceous gland. These tiny glands are intimately associated with the hair follicle. They secrete an oily substance that lubricates both the hair and the surrounding skin. People with oily skin have sebaceous glands that tend to be very active, while those with dry skin put out far less of this natural lubricant. This oily substance continuously makes its way to the surface alongside the shaft of the hair, through the tiny pores in the skin.
The skin is also the home of another type of gland, the sweat gland-not the most glamorous part of the skin, but certainly one of the most important. Sweat glands each have their own tiny pores that open to the surface. The process of sweating is a critical part of the body's temperature-regulation process. When water is secreted from these glands onto the surface of the skin, it helps cool the body through the process of evaporation: the same principle as air conditioning. On a warm day, if you were unable to sweat, your body would rapidly overheat.
Under extreme conditions the volume of water that your body can lose through this process can be as much as a liter per hour. As a band patient that is particularly important, because you may have trouble drinking enough fluids to avoid dehydration. If you become dehydrated, your body will attempt to hold on to all the water it can, and you'll eventually stop sweating. It then becomes critical to get to a cooler place and drink some water, otherwise your body temperature will start to rise uncontrollably. This life-threatening condition is known as heat stroke.
An extraordinary network of blood vessels and nerve endings is found throughout the skin. The nerve endings are particularly fascinating. It doesn't matter where the skin is touched you feel the sensation-but it is far more sophisticated than that. You can easily tell whether you are being poked with a sharp pin or with a blunt finger. You also know the precise location of the contact. In an instant you can distinguish between the touch of a woolen scarf and a silk one. You can even feel the difference between a dry towel and one that is slightly damp. That is pretty amazing if you stop to think about it. For example, if you touch something hot, your hand will jerk back instantaneously, before you are even aware of the pain. While we take all of these things for granted, they are all possible because of the remarkable network of nerve endings contained in the skin.
Skin is affected by excess body fat but doesn't actually store the fat. Immediately beneath the skin is a layer of fatty tissue called the subcutaneous adipose tissue. That is where much of the body's stored fat is located, especially in women.
So, now that you are totally amazed by what your skin actually does for you, we need to shift back to the subject of obesity and discuss what happens to your skin as a result of weight gain and weight loss.
The Effect of Obesity on Your Skin
In most obese people the subcutaneous layer is where most of the excess fat is stored. That is especially true for obese women. As we discussed earlier, men tend to have a somewhat higher percentage of their fat stored inside the abdomen, but obese men also develop a thick layer of fat under the skin. Along with the buildup of these fatty deposits, the skin is also required to expand to accommodate the enlarging body. If the weight gain is gradual, there is a possibility that the skin can actually grow to meet the need. That is more likely in young people with healthy skin than it is in older people.
No matter the age, when weight gain is fairly rapid, or extreme, the skin may not be capable of growing fast enough, so it will merely stretch. This kind of stretching of the skin damages the dense fibrous tissues of the dermis, which provide much of the skin's strength, as well as the elastic fibers that allow the skin to rebound. In other words, the skin can be permanently damaged. The result is what we commonly call stretch marks. They are actually visual evidence of the underlying damage that has occurred as a result of weight gain.
Cellulite
The fat deposited in the subcutaneous layer isn't always smooth and uniform. Sometimes it can be quite lumpy or create dimpling of the skin. This is commonly referred to as cellulite. In reality it is simply irregular deposits of fat. It has nothing to do with the skin, except for the fact that these irregular lumps of fat cause the skin to follow their contour. The dimpling is caused by random fibrous bands that connect the skin to the deeper layers of tissue below the fat. These dense bands of tissue don't stretch as the fat accumulates, and the result is the dimpling that is sometimes called "hail damage" or "cottage cheese skin."
Treating cellulite has grown into a multimillion-dollar industry. A wide variety of lotions and creams are sold with the promise of making this "unsightly skin just disappear." Well, the fact is that cellulite is not a skin condition at all. The appearance is caused by excess fat under the skin. It may seem like the problem is improved after vigorously rubbing the area with that magic lotion, but the effect is due more to the mechanical action of messaging than any chemical that is being applied. The act of applying pressure to the skin can temporarily redistribute the underlying fat. That is why the various wraps and tight-fitting garments seem to improve cellulite as well. Liposuction has been advocated to treat cellulite, but it may actually make the problem worse because it can cause even more irregularity of the fat deposits. The best treatment for cellulite is weight loss, period.
Skin Fungus
One of the most common problems associated with obesity is the red rash that develops between the folds of skin, especially under the breasts, in the groin, and under a large overhanging abdomen. This is a fungal infection in the skin, and the medical term is intertriginous moniliasis. Everyone has tiny fungus spores on the surface of the skin, but they require certain conditions to cause an infection. You can think of skin fungus as being a close relative of the mushroom. To grow it requires a warm, moist, and dark place where food is abundant. This perfectly describes the space between the folds of skin: the deeper the fold, the more warmth, moisture, and darkness. The skin itself provides the nourishment.
Athlete's foot is caused by essentially the same fungus, and there are numerous antifungal powders and creams available to treat this condition. There are also prescription medications, both topical treatments and antifungal pills, that can help control these kinds of infections. But, unless you eliminate the environment that supports fungal growth, it will come right back. That means you need to keep the area dry and cool-not an easy task when gravity continues to slam those folds together.
Antifungal powders may help to absorb some of the moisture, but they have to be applied frequently. Placing an absorbent cloth between the layers of skin may also help, but the cloth tends to slide out and must be repositioned frequently. Probably the best treatment is to lie in a cool, dry place and expose the infected area to the light for 30 minutes to an hour, two or three times a day. It doesn't sound very practical, I know, but when combined with other antifungal treatments, it works.
This type of fungal infection frequently damages the skin, causing permanent discoloration and visible scarring. If the infection is severe enough or is present for an extended period, a secondary bacterial infection of the skin may occur. Patients with diabetes are particularly prone to both fungal and bacterial skin infections because of their impaired ability to fight infection. Fungal infections of the skin are rarely ever serious and they are almost never life threatening, but if the fungus gets into the bloodstream it can cause an extremely serious infection.
The Effect of Weight Loss on Your Skin
While gaining weight has the potential to stretch, pucker, and even injure your skin, you would assume that losing weight would undo all that. Unfortunately, that generally isn't the case. After major weight loss the excess skin can make some patients feel like a shar-pei puppy.
I get asked all the time, "How can this happen?" The answer is simple: the skin used to be full of fat; the fat went away, leaving the empty skin behind. In most cases when the skin becomes damaged by the stretching process, it loses much of its elasticity. Certainly, this varies from patient to patient and depends on many factors. The main ones are how much stretching has taken place, the part of the body involved, the duration of the obesity, the age of the patient, the general health of the skin, and how rapidly the weight is lost. You can't control most of those factors, but you can influence the health of your skin and how quickly you lose the weight.
Even damaged skin will likely retain some of its elastic properties and will tighten up with time. Losing weight slowly may allow the skin to rebound to some extent as the fat stores shrink. That is not always the case, however, especially in cases of extreme obesity. And younger patients are more likely to experience this skin retightening than older individuals, regardless of the rate of weight loss.
Fat distribution varies considerably from one person to the next. Some people carry most of their weight in and around their abdomen. Others have more fat on their hips and legs. Still others may have a very heavy chest, neck, and shoulders. As a rule, the parts of the body that are farthest from the core tend to be affected the least, so the skin of the feet and hands, the lower legs, and the forearms gets stretched less than other areas. As you lose weight the skin in these areas is much more likely to shrink back to its normal size without showing any permanent damage.
The feet and ankles can certainly become swollen, however, especially if obesity is accompanied by venous congestion and chronic swelling. In that case the problem is the accumulation of water in dependent tissues with poor circulation, called edema. All the tissues, not just the skin, become boggy as the blood pools in your feet and ankles.
The presence of chronic edema causes the skin to become thicker, and with time the color will become darker. These areas are very susceptible to ulcerations, called venous stasis ulcers, that are very slow to heal. To a lesser degree these same skin changes, especially the thickening and discoloration, can occur in any area that has become abnormally dependent. It's common on the underside of the breast, the inner thighs, and especially the bottom of a large abdominal "apron," called a pannus.
Because the skin of the upper arms and thighs is subject to more stretching, it tends to remain that way even after significant weight loss. The folds of skin in the groin area are also more likely to have suffered from fungal infection because of moisture and irritation. Even with major weight loss these folds and the infections that occur there are likely to persist. The same thing can be said about virtually every other area that has been subjected to chronic obesity.
Peter's Story
(Left) Peter, pre-op, 407.2 pounds.
(Right) Peter, three years post-op, 219 pounds.
My sister and brother-in-law are both physicians, and they were both concerned along with the rest of my family about my weight. So Christmas of 2001, my brother-in-law, whose specialty is internal medicine, trapped me in the car for over an hour. He took advantage of the opportunity to lecture me about my weight and weight-loss surgery. He knew I'd done the various weight-loss diets and even some weight-loss drugs. I did well on a couple, losing 80 to 90 pounds, but the pounds came back, along with friends.
I told him I'd think about it, and I did for an entire year. I looked at the various surgical options available and decided it was the band I was interested in. In March of 2003 I made the appointment with my band surgeon. I went twice, and he answered all of my questions each time. I booked the surgery for June of 2003, but it got canceled because of the SARS crisis in Canada, where I live.
Pre-op I weighed in at 407.2 pounds, and I'm 6 feet, 1 inch, so my BMI was 52. My condition had the depressing title "super obese." I chose to get the Swedish 9cc band. I've had no complications. Actually, that's just blown my mind. I haven't vomited, and I've had no reflux. I did have reflux before the band. Basically, the band is keeping the acid from rising up past it, so it cured my acid reflux.
The only problem I've had was an incident with French bread. I'd finished one scrambled egg and a slice of French bread when intense pain started in my chest where the band is. So I went to the sink, thinking I'd throw up. I didn't; I had to wait it out. But I haven't had a slice of bread since. I now avoid any bread that balls up if I roll it between my fingertips. Once in a blue moon I do have sliming, but never followed by vomiting. That's happened when I've rushed eating. So essentially I feel I've had no problems at all.
The very first week after surgery I lost 17 pounds. I thought it was water weight. The following week I took off another 6 pounds. It kept going like that and I lost 205 pounds altogether in 14 months, which averages out to about 4 pounds a week. I remember that once or twice I lost only 1 or 2 pounds one week and got annoyed.
Now, three years post-op, I couldn't be more happy. I've kept the weight off. I'm 219 now. I'd like to be at 215, and my lowest weight was 202. But at 202 some people said that I looked too thin, that my face looked emaciated, and I remember my port was sticking out. I had a sternal placement of my port, and it looked like I'd swallowed a golf ball. So I asked my band surgeon to move it during one of my plastic surgeries; it's now an inch away from my belly button and doesn't stick out.
All my fills have been done under fluoroscopy. For some reason my surgeon cannot do them the other way. I have 5ccs in my 9cc band now, and I'm delighted with that. My surgeon did remove some of my fill for the first of my plastic surgeries, but he's recently told me that there's no need for that anymore for surgery not related to the band.
Normally exercise is a big part of my weight loss. I work out three times a week at the gym, since I live near one. I do upper and lower body work for an hour and a half. I swim twice a week for more than an hour. I take a brisk walk for an hour a day, and in the summer I extend that to two or three hours. Most people say walking doesn't do much, but I enjoy it. I also participate not so consistently in other activities, such as yoga, pilates, and squash.
My life is very different now. This is a guy who never used to exercise before the band. I was very lazy. Now I really do enjoy all types of exercise. I'm not demoralized by being out of breath all the time, as I was doing ordinary activities. I enjoy being able to blend into the crowd, not standing out, not having people stare at me.
My pants went from a size 54 to a size 36. My shirts went from a 4x or 5x down to Large. I feel so much better about myself. I didn't mind any longer looking at my reflection in store windows. Now I actually go out of my way to look.
I enjoy the non-scale victory things, too, like no longer needing a seatbelt extender on the plane. I used to ask for the extender in a sneaky way, whisper to attendant, and she'd bring it to me discreetly. The last flight, I had slack in my seatbelt and I could pull down the tray table. Before, my meals used to slide off the tray table because I was too big for it to lie flat.
I enjoy not having to go to the big and tall shop. I now buy designer stuff at discount prices. Though, there for a while, I spent too much money on clothes. When I was at 400 pounds, I bought what I had to. I never threw anything away, so I kept all my clothes from the way up. I recently got rid of 10 garbage bags full of clothes. I did keep one pair of the fat pants, and now both my legs fit in one leg of those pants. I have a photo of me with another band patient. She is in one leg of the pants and I am in the other.
Other medical problems cleared up besides the acid reflux. I had sleep apnea and needed a CPAP machine. Once I'd lost 100 pounds, that went away. And I had severe knee pain, and that's gone.
I think my most important piece of advice for other band people is to follow the rules most of the time. I never drink beverages with meals, and I wait an hour afterward to drink anything. I don't have pop at all; no beer, either. I eat protein first, then vegetables, then carbs. I do have cookies once in a while. I used to have a whole bag at a sitting, but now I have two or three and stop. I'd also caution people not to eat so they throw up regularly.
I think the band is a great tool, and everyone should know about it. My background is in science, and the idea in science is to look for the simplest theory or approach to solve a problem. I think the band fits that description-it's a terrific and simple solution.
Minimizing the Damage
We all want young, healthy skin, right? Unfortunately, as you get older your skin ages along with you, and there is no such thing as a fountain of youth. Time marches on for all of us. But some people have skin that is more youthful in appearance. For some, this is genetic; they're blessed with naturally healthy skin. For others, their skin remains healthy because they work at it. They avoid using harsh soaps, apply moisturizing lotions regularly, and perhaps most important, they stay out of the sun.
Did you ever wonder why your skin tans as a result of being out in the sun? As I mentioned earlier in this chapter, ultraviolet rays stimulate melanocytes to make more melanin pigment that's "how" the skin tans. But the reason the skin gets darker is that the melanin helps block those ultraviolet rays from penetrating into the deeper layer of the skin, the dermis. That is where real damage can occur to the blood vessels, nerves, and supporting structures. The pigment is the body's way of trying to protect itself from the harmful UV rays.
With prolonged exposure to the sun or other artificial sources of ultraviolet light (tanning beds), the result will eventually be permanent damage to your skin. Over time your skin will become leathery, thicker, and less flexible than normal. You'll also have more wrinkles, and you may even lose some of your sensitivity to touch. When chronic sun damage is combined with major weight loss, it can create some very unsightly results.
Ultraviolet radiation also increases your risk of developing skin cancer, including one of the more aggressive forms of malignancy, melanoma. That may not have anything to do with obesity and weight loss, but it is an important message to take into account when caring for your skin. The bottom line: for healthier skin, stay out of the sun and the tanning bed. If you are going to be out in the sun, you should either wear protective clothing or apply a sunscreen with an SPF (Sun Protection Factor) rating of at least 15 to all exposed areas.
Skin-care Products
If you go to any drug store, department store, hair salon, or grocery store, you can't help but be exposed to the unbelievable number of skin-care products that are on the market. If you go online, the selection is seemingly limitless, and the cost of some of these products is utterly astounding. It is well beyond the scope of this book for me even to attempt to comment on the relative effectiveness of any specific lotion, cream, ointment, salve, liniment, gel, body rub, or balm.
Without question, many skin-care products can help promote healthy skin, either by promoting healing or providing protection. The lubricating and protective effects of natural substances like lanolin, an oil secreted by the sebaceous gland of certain sheep, have been recognized for centuries. Interestingly, lanolin is one of the main ingredients in shoe polish because of its ability to help keep "tanned leather" soft.
There are many "natural" products such as aloe vera, camellia oil, cocoa butter, coconut oil, lavender oil, avocados, seaweed, emu oil, green tea, etc., etc., etc., that are touted as being capable of rejuvenating, regenerating, tightening, firming, or (my favorite) "youthening" the skin, whatever that means. There are even some skin-care products that say they offer breast enhancement! But it's important to recognize that manufacturers of skin-care products don't have to demonstrate the effectiveness of their products the way drug manufacturers do. Skin-care products are classified as cosmetics, and therefore they are not regulated by the Food and Drug Administration (FDA). The following statement comes directly from the FDA website, and it sums up this issue pretty well: "The Food, Drug, and Cosmetic Act defines drugs as those products that cure, treat, mitigate or prevent disease or that affect the structure or function of the human body. While drugs are subject to an intensive review and approval process by FDA, cosmetics are not approved by FDA prior to sale. If a product has drug properties, it must be approved as a drug."
For those patients who are experiencing problems with their skin, the best advice is to consult a dermatologist-a physician who specializes in the diagnosis and treatment of skin conditions. In the long run, getting the advice of a dermatologist may save you a small fortune in over-the-counter treatments. But even the dermatologist isn't going to have an answer for all that excess skin that's hanging off your now more slender body. For that, you'll likely need a nip and a tuck, which is the subject of the next chapter.