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/ Source: TODAY
By Meghan Holohan

Even after Jacqueline Adan lost 350 pounds, she knew her journey wasn't over.

The excess skin spilling off her belly, legs, arms and breasts caused pain and made it difficult for her to see the results from her weight loss. She wondered how long she could live with the discomfort.

“I would take the loose skin over being 500 pounds, but I wasn’t living my best life,” the 32 year old from the San Francisco Bay area, told TODAY. “I went to my regular doctor complaining about the skin. It was causing issues not only physically, but also mentally.”

While plastic surgeons offer various procedures that remove the loose skin and lift parts of the body that sag after weight loss, insurance companies consider these procedures cosmetic and do not cover them. Adan knew she was on her own.

“No one was helping me," she said.

Adan, who shares her experiences at Jacqueline's Journey, met Dr. Joel Beck, a plastic surgeon at Bay Area Aesthetic Surgery, who knew various procedures could help her quality of life. Adan first had a lower body lift, which removed the skin around the stomach and back and lifted up her bottom and pubic area.

The difference was immediate.

“When I looked down and I didn’t see any of that skin on my stomach or I went to shower I didn’t have to lift it up," she said. "I started hysterically crying.”

Recovery was painful but she knew it would benefit her health in the long.

“It was worth it,” she said.

What is skin removal surgery?

After people lose a lot of weight their skin often hangs off their body, giving a deflated look. The heavy folds of excess skin can cause health problems such as frequent infections and pain.

“You are going to have laxity and excess skin folds, which leads to functional issues such as the skin getting in the way during exercise and activities,” Dr. John Fischer, an assistant professor of surgery and director of the clinical research program at the University of Pennsylvania Health System, told TODAY. "It can lead to wound issues."

While insurance normally doesn’t cover skin removal, it sometimes pays for a procedure called a panniculectomy, when doctors remove a fold of skin. While that might fix some of the problems, patients often dislike how it looks because it doesn’t include any contouring. Still, Fischer and other plastic surgeons try to obtain documentation of patient problems to submit to insurance for partial coverage.

“The insurance companies have very specific criteria,” Fischer said. “We have to advocate very, very loudly for patients.”

Doctors want most patients to be done losing weight before they perform skin removal procedures.

“You always want to wait until they get to their lowest point,” Beck told TODAY. “Three to six months after they plateau and they are not losing more weight, that is the time I would consider it.”

Patients with complications, such as uncontrolled diabetes or extremely high blood pressure, do not qualify for surgery, although patients who typically seek skin removal are healthy.

“Many of the patients who lose significant weight reverse many of their medical conditions and they are in a healthy state,” Dr. Michele Shermak, a plastic surgeon in the Baltimore area, told TODAY.

While patients who shed massive amounts of weight often need multiple procedures all over the body, some patients carry only extra skin around their midsection and can get a tummy tuck, or what’s also known as a mommy-makeover to tighten it.

“Most people come to get the abdomen done. It is often the first area they like to address,” Shermak said.

The mental impact of skin removal.

Adan’s reaction to the excess skin isn’t unusual.

“Patients will tell you they feel like they are living in someone else’s body and they haven’t completed their journey,” Dr. Alan Matarasso, president of the American Society of Plastic Surgeons and clinical professor of surgery at Hofstra University, Northwell School of Medicine, told TODAY.

Lexi Reed, known as Fat Girl Fed Up on Instagram, lost 312 pounds and also coped with loose skin. It made exercising tough, but she had no idea how much pain it caused her until her husband, Danny, lifted it, and she felt immediate relief.

“I would be in tears. I would be in so much pain that I thought something was happening to me or I was dying,” the 28-year-old from Indiana told TODAY.

Last Halloween she had a 360-bottom lift. Her doctor removed seven pounds of skin from her stomach and back while lifting her butt and reconstructing her abs. She also had the sides of her legs lifted.

Recovery was challenging. The first time she sat up she sobbed. She had drains hanging off her and wore compression garments for weeks, all common during recovery from skin removal. But the pain was worth it.

“I felt all the emotions. For once in my life I could see my toes. For once in my life I could see my belly button. I didn’t even recognize myself in the mirror,” she said.

In September she’s undergoing a 360 top-lift and admitted she’s “nervous but excited.”

While Adan had about seven procedures, her last one on her legs came with one serious potential complication from surgery — poor wound healing or “flap necrosis,” where the skin dies. She needed a skin graft to heal properly. Wound healing and fluid build up are the two most common complications from such procedures.

“Sometimes they get fluid collection under the skin,” Matarasso explained.

Even with a second surgery and longer healing time, Adan is happy with her surgeries. She worked with a lawyer to help navigate insurance coverage and reached a resolution.

“I don’t regret any of the decisions I made with skin removal,” she said. “Six to eight weeks of my life to recover is worth it for the rest of my life to be pain free.”