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 wasnât just the extra skin left behind on his torso and legs. Like most morbidly obese people, Brian expected to undergo so-called âbody contouringâ to remove that excess flesh.
What he didnât 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.
âYouâre so overwhelmed with the joy of losing the weight, but thereâs this point of realization,â Brian says. âYou look in the mirror and you say, oh, thatâs not good.â
Brian, 60, is among a little-known group of bariatric patients who require facial restructuring in the wake of massive weight reduction.
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.
âThe skin tends to re-drape more favorably in the face and neck than it does in other parts of the body,â 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: âI looked like everything had melted.â
ASPS figures show that member surgeons performed nearly 53,000 body contouring operations â" reshaping of breasts, arms, thighs and stomachs â" 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. Itâs less common than body surgery, Roth says, partly because some faces adjust better  â" and partly because while insurers often balk at paying for body contouring, theyâre even less likely to cover costs above the neck, says Roth. The financial reality of a $20,000 bill can be a deal-breaker.
âFor the face, itâs going to be an uphill battle,â Roth says. âThere are plenty of people walking around with loose necks and they didnât have massive weight loss and they want a face lift.â
Brian says heâs 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 â" and drool
The huge weight loss reduced his neck from 22 inches to 16 inches â" 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.
âWhatâs happening is his neck is so large because of the extra skin,â says Dr. Lawrence S. Zachary, an associate professor of surgery at the University of Chicago Medical Center, who performed Brian's body lift. âThe muscles are pulling things down, making it hard for him to talk without drooling.â
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.
âYou just donât know how this affects me,â 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 canât 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 heâs 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.
âHeâs having a hard time maintaining the competence of his mouth because of the pull,â says Zachary. âItâs medically necessary surgery.â
A representative for Blue Cross/Blue Shield did not immediately respond about Brianâs 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 â" 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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