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Paul Brian
Paul Brian, 60, of Chicago, lost 240 pounds, but it left him with sagging facial features that impede his ability to speak and require plastic surgery to fix. He believes insurance should cover the cost, but it's been denied several times.
Image: JoNel Aleccia
By JoNel Aleccia Health writer
TODAY.com
updated 12/12/2011 8:34:16 AM ET 2011-12-12T13:34:16

Back when he weighed 420 pounds, Paul Brian thought losing the weight would be the hard part.

But after shedding 240 pounds with the help of bariatric surgery six years ago, the Chicago radio announcer and PR man found that reducing his girth by half spawned new problems.

It wasn’t just the extra skin left behind on his torso and legs. Like most morbidly obese people, Brian expected to undergo so-called “body contouring” to remove that excess flesh.

What he didn’t expect, however, was to wind up with a face and neck so disfigured by sagging wrinkles and flaccid muscles that plastic surgery seemed the only option.

“You’re so overwhelmed with the joy of losing the weight, but there’s this point of realization,” Brian says. “You look in the mirror and you say, oh, that’s not good.”

Brian, 60, is among a little-known group of bariatric patients who require facial restructuring in the wake of massive weight reduction.

Courtesy Paul Brian
Before he had weight loss surgery in 2006, Paul Brian, a Chicago radio announcer, weighed 420 pounds.

Many people who lose lots of weight adjust gradually when it comes to their faces, said Dr. Malcolm Z. Roth, president of the American Society of Plastic Surgeons and chief of plastic surgery at Albany Medical Center in New York.

“The skin tends to re-drape more favorably in the face and neck than it does in other parts of the body,” he said.

In other cases though, substantial weight loss leaves formerly fat people with under-eye bags, slack jaws and so many wrinkles that it led one online patient to comment: “I looked like everything had melted.”

ASPS figures show that member surgeons performed nearly 53,000 body contouring operations — reshaping of breasts, arms, thighs and stomachs — after patient weight loss in 2010. Overall, nearly 200,000 people each year undergo bariatric surgery, according to the American Society for Metabolic and Bariatric Surgery.

But there are no similar statistics for people who needed facial plastic surgery after losing weight as well. It’s less common than body surgery, Roth says, partly because some faces adjust better  — and partly because while insurers often balk at paying for body contouring, they’re even less likely to cover costs above the neck, says Roth. The financial reality of a $20,000 bill can be a deal-breaker.

“For the face, it’s going to be an uphill battle,” Roth says. “There are plenty of people walking around with loose necks and they didn’t have massive weight loss and they want a face lift.”

Brian says he’s been fighting the battle for facial surgery for years, ever since he finished losing weight after a 2006 duodenal switch, a rare form of bariatric surgery.

Heft jowls, extra neck skin — and drool
The huge weight loss reduced his neck from 22 inches to 16 inches — and left him with hefty jowls and a wattle of flesh under his chin, all so heavy that they interfere with his speech and his hygiene, his doctor says.

“What’s happening is his neck is so large because of the extra skin,” says Dr. Lawrence S. Zachary, an associate professor of surgery at the University of Chicago Medical Center, who performed Brian's body lift. “The muscles are pulling things down, making it hard for him to talk without drooling.”

Paul Brian
Brian, 60, a radio announcer and PR representative, says his life is vastly improved, except for the complications caused by extra skin and drooling.

Indeed, Brian says he has to keep a handkerchief available at all times and must sleep with his head face-up and completely square on his pillow to keep from soaking the bedding.

“You just don’t know how this affects me,” he says.

Brian would like to get the problem fixed, but after paying out of pocket for most of the costs of the $40,000 weight-loss surgery, and for $30,000 in reconstructive surgery for his body, he can’t afford the additional $20,000 or so it would take to do his face.

He has submitted the bills to Blue Cross/Blue Shield of Illinois, the company that insures his employer, the Chicago Automobile Trade Association, which puts on the Chicago Auto Show. But he’s been rejected several times, essentially because the procedure is regarded as cosmetic, his records show.

Brian and his doctors argue that in his case, vanity takes a back seat to function. Brian is a radio announcer who hosts a weekly automotive show and a public relations representative whose livelihood depends on lots of talk.

“He’s having a hard time maintaining the competence of his mouth because of the pull,” says Zachary. “It’s medically necessary surgery.”

A representative for Blue Cross/Blue Shield did not immediately respond about Brian’s specific case, but many insurers routinely decline to pay for weight loss surgery itself, let alone operations to remove extra skin afterward. Brian has appealed the decision several times and plans to do so again.

Losing such a substantial amount of weight was nothing less than life-saving — and life-changing, Brian says. And now he just wants to finish the job.

"If history has taught me anything, you don't give up hope," he says. "Somewhere, somehow, a solution will occur."

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