Surgery for loose skin: what is panniculectomy surgery?

If you have recently lost a significant amount of weight, whether through bariatric surgery, weight loss medications, or other interventions, you may notice changes in your physical appearance and body shape. 

In addition to feeling lighter, you could be seeing some new wrinkles or excess skin in areas you didn’t quite expect. One of those areas could be around your belly. A large flap of excess skin hanging from your abdominal area is known as a panniculus, and it can be surgically removed with a panniculectomy.

A panniculectomy is a body contouring surgery that removes the excess skin and fat tissue, known as a “panniculus” or “apron,” that hangs over the abdomen after significant weight loss. The panniculus may extend far past the stomach, ranging from the abdominal area down to the pubic area, hips, and in extreme cases even close to the knees. During the procedure, a plastic surgeon uses special equipment to hold up the flap while they remove the excess skin and fat under the skin, changing the shape of your abdomen and contouring the abdominal wall.

It’s common to have areas of excess skin after significant weight loss. Your skin is elastic and stretches to grow with increasing body weight. However, sometimes you lose weight faster than your skin can bounce back. This is especially true for people who lose massive amounts of weight, such as with bariatric surgery. 

The panniculus, a large flap of overhanging skin, can impact how a person feels about their appearance, and it can also affect how they can move around, as excess skin can be an obstacle. For example, it can weigh a lot, putting pressure on the person’s bones as they move around. It can slap against their legs as they walk, causing discomfort that may make them want to avoid exercising — increasing the risk of rebound weight gain. And the folds of skin can rub against each other, creating moisture and irritation that may develop into a rash or bacterial or fungal infection.

Panniculectomies are different from abdominoplasties, or “tummy tucks.” While a tummy tuck may also remove excess skin, it is purely a cosmetic procedure designed to improve the appearance of the abdomen by making it look thinner and firmer by tightening the layers of abdominal muscle and fascia underneath. On the other hand, a panniculectomy focuses exclusively on removing excess skin to improve physical functioning first and foremost.

Both procedures can be performed at the same time, or can be combined with other abdominal procedures (more on that below).

Panniculectomy surgery may be recommended after a person experiences drastic weight loss, leaving a large amount of excess skin hanging from their lower abdomen over their groin, pubic region, thighs, or legs. While getting a panniculectomy after bariatric surgery is common, many people get a panniculectomy independent of bariatric surgery. 

Ideally, you should be in good health, and have maintained a stable weight for at least six months. The excess abdominal skin should hang at least below your pubic area, and interfere with your mobility, personal hygiene, and day-to-day life, perhaps even causing rashes or infection. 

However, not everyone is a good candidate for a panniculectomy. For example, your healthcare provider will ask you if you have any of the following conditions to make a decision if the procedure is right for you:

• Heart disease, lung disease, uncontrolled diabetes or other medical conditions that may affect wound healing or risk of postoperative complications

• Immune disorders, as they can also interfere with wound healing and increase your risk of infections

Smoking, obesity, and diabetes raise your risk of experiencing an infection or other complications during recovery. Additional risk factors include having at least one other pre-existing health condition (including chronic obstructive pulmonary heart disease or hypertension), being male, and being older than 60.

Before the procedure, your health provider may recommend making certain changes to expedite healing and reduce complications after the surgery. They will tell you to stop smoking or to avoid secondhand smoke. They may also recommend increasing your protein intake or taking certain nutritional supplements, and adjust the dosage of medications or over-the-counter supplements you are taking, or ask you to stop taking them temporarily.

As a surgical procedure, a panniculectomy is not without risks. In one study, around one in five people experienced a complication from their panniculectomy, such as a wound infection. 

People who have had bariatric surgery, have other health conditions or have a higher body mass index (BMI) going into surgery may be more likely to experience complications after a panniculectomy. However, complications are more common among people with extreme obesity. For example, as many as 42% may experience wound healing issues after a panniculectomy that removed more than 22 lbs of excess skin— the incidence of serious complications that require surgical intervention is much lower, around 11%. Also, the surgery is performed under general anesthesia, which can carry some risks. 

Here are some common complications that can happen during recovery.

Seromas

Seromas are the most common complication of a panniculectomy. A seroma is a buildup of clear fluid that may accumulate when an empty space develops in the body. This is a risk with a panniculectomy, given the large amount of excess skin and fat that is removed. 

To prevent seromas, suction drains will be placed during the panniculectomy to suck up the extra fluid while you heal.

Wound healing complications

Wound healing issues can occur after a major surgery like a panniculectomy. During the procedure, the surgeon will make an incision in the lower skin fold of the pannus and then extend and deepen it. Once the excess skin and fat are removed, the surgeon will close the wound in multiple layers. Suction drains, sutures, and abdominal dressings will be used to help with wound healing and prevent issues. 

Sometimes wounds open before adequate scar tissue has formed. In one study, this occurred in about a quarter of cases. To prevent this, you’ll be advised to be careful about moving around, sitting, and standing up in the first few weeks after the procedure. 

At first, the surgeon recommends staying bent over at the waist around 30 degrees. After about a week, if all goes well, you can slowly start standing upright again, with the help of abdominal pads (these thick dressings help with draining wounds).

Other risks and complications

The average hospital stay for a panniculectomy is 2 days. Once you go home, you may continue to experience swelling, bleeding, and pain. When a buildup of blood occurs, it is called a hematoma. While suction drains can help remove the hematoma, it may need to be surgically removed if it doesn’t stop bleeding or gets more prominent. 

Blood clots, scarring, and tissue death (necrosis) can occur after panniculectomy. You may also experience a skin infection called simple cellulitis, which can be treated with antibiotics. 

Finally, 3% to 12% of people may need to redo the surgery.

Panniculectomies can significantly improve quality of life. One survey of over 180 patients who underwent a panniculectomy or an abdominoplasty reported dramatic improvements in quality of life, even if they experienced a complication from the procedure. 

It takes time to recover from the surgery. Your health provider may recommend avoiding physical activities for several weeks after the operation. Wearing compression garments while you still have the drains in may prevent a seroma from forming and help you feel more comfortable post-surgery. You’ll also be given a lot of pain medication.

It’s hard to determine the exact procedure cost without talking to your healthcare provider and insurance. Without insurance, a panniculectomy can cost more than $10,000, depending on where you live. How much you eventually pay for a panniculectomy procedure, and whether or not it is covered, will depend on your insurance plan. Generally, portions of panniculectomies are covered by insurance because they're not considered cosmetic surgeries. But, your insurance provider may require a few things before covering the procedure. 

For example, Medicare requires prior authorization to approve coverage for a panniculectomy. Your health provider will need to send Medicare a prior authorization request and documentation stating that it is medically necessary for you to have the procedure. 

Health insurance plans may require your health provider to demonstrate that it is medically necessary before they will provide coverage. The specific criteria can vary depending on your plan, but generally, they may require:

• A description of the pannus, with photographs that show that the hanging skin extends to below your pubic area

• Documentation that the pannus is causing intertrigo (an inflammatory skin rash caused by moisture and skin folds rubbing against each other), and that medication and good hygiene have not relieved the intertrigo

• A description of how the pannus is interfering with your daily functioning, such as trouble walking, exercising, or going about your life

• Confirmation that you have maintained a stable weight for at least six months

Surgery is generally the best option for removing large amounts of excess skin. Besides a panniculectomy, your health provider may consider other reconstructive procedures depending on where you have excess skin, how it is affecting your life, and whether any underlying health conditions may affect your candidacy for the procedure. These may include:

• Liposuction: Liposuctions may be combined with excess skin removal surgeries to remove any areas of localized fat.

• Circumferential lower body lift (CBL): CBLs combine a tummy tuck, butt lift, and lateral thigh lift to remove large amounts of excess skin around your waist, abdomen, and butt.

• Mons pubis reduction: This procedure focuses on drooping skin and excess fat in the pubic area, using either surgical removal of the skin, liposuction, or both.

• Medial thigh lift: A thigh lift may be performed during a CBL or on its own to remove hanging folds of skin in the mid to lower thighs.

• Autologous gluteal augmentation: Sagging skin often shows up in the buttocks after massive weight loss, causing a deflated appearance of the butt. Surgeons can transfer tissue from the upper butt to add more volume during a lower body lift.

• Breast lift or reduction: Like the butt, excess loose skin can affect the breasts. Surgeons can fix this with a breast lift (mastopexy) or a breast reduction, depending on how much subcutaneous fat tissue there is. 

• Autologous breast augmentation: Similar to how surgeons may increase butt volume by using tissue from the upper butt, an autologous breast augmentation uses tissue from the armpits and chest to fill out breasts that have become droopy due to weight loss.

• Torsoplasty or back lift: Large folds of skin that drape across the back can be removed with liposuction, a CBL, backlift, or torsoplasty.

• Axilloplasty: This surgical procedure removes excess skin and fat in the armpit and “side boob” area to recontour the armpits. It may be combined with a breast or back procedure.

• Brachioplasty: A brachioplasty addresses the “bat wing,” or the extra skin that can hang and jiggle underneath the upper arm. 

Our bodies hold on to fat in different areas depending on our age, sex, and other factors. If excess skin is affecting your emotional and physical quality of life, talk to your health provider. They can recommend the best treatment plan for you depending on where the excess skin is, how it is affecting you, and your medical history. 

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Current version

July 17, 2023

Written by

Amelia Willson

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.