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Interviewer: After a person has experienced major weight loss, either through lifestyle changes or something like a bariatric surgery, you may be left with a bit of excess skin that just won't seem to go away. And there are a few surgical options available to help remove that skin. Dr. Brad Rockwell is a professor of plastic surgery at University of Utah Health.

Now, Dr. Rockwell, when it comes to the excess skin from weight loss, how common is it for someone to have excess skin that just won't seem to go away?

Dr. Rockwell: Oh, virtually 100%. Unfortunately, as we get older, our skin loses some of its collagen, loses some of its elasticity, and the skin will become loose. So, even at certain ages of maturity, even if someone is not overweight, they will still have some lax skin in their abdomen. For everyone that's lost weight, virtually 100% will have some extra skin that could be improved with abdominal surgery.

Interviewer: So the surgery is an abdominoplasty, correct?

Dr. Rockwell: Correct.

Interviewer: And it's my understanding that there's a gradation of how much skin, and that kind of relates to what kind of surgery that you as a plastic surgeon would perform. Why don't you walk me through some of these treatments and kind of walk me through how they work and what a patient could expect?

Dr. Rockwell: There's the standard abdominoplasty. The non-medical term for that is tummy tuck. That's also essentially one of the main components of a Mommy Makeover. But it's just loose skin in the abdomen. In addition to the loose skin, usually the muscles beneath. If it's in a female who's had a pregnancy, the muscles will be a little loose. The skin may have some redundancy.

And the standard abdominoplasty or tummy tuck will remove skin in the lower portion of the abdomen. The skin that is higher on the abdomen is stretched to close where the skin was removed. And in addition, the six-pack muscles or rectus muscles are tightened and that will narrow the waist.

Interviewer: Okay. So it's not just the skin that you're operating on. It's also the muscles underneath?

Dr. Rockwell: Right, by tightening the underlying muscles. No muscle is cut. No muscle is thrown away. The muscle is still fully functional. There's some experimental evidence that actually shows the tone in the muscle is increased and athletic performance may be boosted a little by tightening the muscles. But the muscle is tightened. That will narrow the waist and that actually allows more skin to be removed because the inside becomes a little smaller.

Interviewer: Ah, got you. So what's the next stage of treatment?

Dr. Rockwell: So the standard abdominoplasty that we just talked about will pull the skin from the upper portion of the abdomen down lower and remove skin in the lower abdomen. Some people who have lost more weight will have a vertical skin redundancy and also a transverse skin redundancy. So the skin can be tightened by pulling it down, and the skin could also be tightened by pulling each side towards the middle of the abdomen.

The standard abdominoplasty leaves a longer scar in the lower abdomen. It goes from one hipbone to the other hipbone. The second stage does everything that a standard abdominoplasty would do, but in addition tightens skin from side to side, and that leaves an additional scar along the vertical midline of the abdomen. It goes from the bottom of the breastbone down to the pubic bone.

Interviewer: Okay. And so that's for, say, someone who has additional excess skin on the sides, love handle area, or . . .

Dr. Rockwell: It would be someone who's probably lost 50 pounds or 100 pounds. Standard abdominoplasty, maybe the people haven't lost weight. Maybe they've actually gained a little bit of weight from their younger days.

So this second stage, which is also called a fleur-de-lis, which is a French term, that will tighten side to side. And most of those people have lost probably 50 to 100 pounds.

Interviewer: And so as we go onto the last stage, this is for people who have lost a lot of weight. Tell me a little bit about this Stage 3. And I hear that it was a procedure that was developed by someone from the University of Utah?

Dr. Rockwell: Yeah. So the third stage is called a corset abdominoplasty. Dr. Alex Moya, who was a plastic surgery resident at the University of Utah in the early 2000s, now practices in Pennsylvania, and he developed this surgery.

So it incorporates everything that a standard abdominoplasty would do and everything that a fleur-de-lis abdominoplasty would do. And in addition, he pulls skin from the upper portion of the abdomen up towards the chest. The downside of it is it adds a scar right under the chest, or in women right under the bottom of the breast. But it allows even more skin to be removed compared to the other two options.

Interviewer: When it comes to deciding which surgery to do . . . I've heard you kind of discuss it depends on how much weight has been lost, how much excess skin. How much does the scarring come into that decision-making?

Dr. Rockwell: For most of these people, scarring is a secondary concern. Removing the extra skin is more of a concern. Obviously, if someone is in clothing, the scars are not visible at all.

And the majority of people who have the fleur-de-lis abdominoplasty or the corset abdominoplasty may not be on a beach exposing their abdomen. They may have little more modest clothing to cover it up, and then the scars would not be visible at all. But even if they're in that clothing and had not had surgery, the redundant skin and the rolls of extra skin would show through their clothing.

So, for most of these people, the priority is removing as much skin as possible, and the secondary concern would be the scarring.

Interviewer: So, for patients that are choosing to have this procedure done, is it an outpatient procedure? Are they in the hospital for a few days? And how long does it take to get back to your day-to-day life?

Dr. Rockwell: So just about everyone that has any of the three versions of a tummy tuck that we have discussed, it would be performed as an outpatient. The reasons to stay overnight would usually not be specifically related to the involvement of the surgery, but would depend on pre-existing medical conditions.

So if someone had lung trouble or heart trouble and their lung doctor or heart doctor might say, "You need to be monitored overnight in the hospital after that surgery," that would be the reason to stay. But most of them, it's an outpatient operation.

Interviewer: After they get home, what is the recovery time, and what are the steps of recovery, and how long will they expect to be recovering for?

Dr. Rockwell: So if someone has a desk job, they would probably be able to return to a desk job after two weeks. If they have a job that's a little more physically demanding, maybe three weeks.

In tightening the muscle, there's a six-week recovery period to resume exercise. Where the muscle is tightened, it takes six weeks for the muscle to heal where someone could attempt to do a sit up. So the long point of recovery would be six weeks to resume exercise or six weeks to lift more than 10 to 15 pounds.

Interviewer: So, for patients that might be interested in a procedure like this, what should they be looking for when it comes to choosing a good surgeon who will be able to give them the best results possible?

Dr. Rockwell: So none of these options of an abdominoplasty are small operations. They usually require between three and maybe six or seven hours in the operating room. So you want to make sure you have a qualified surgeon.

The best level of qualification that the public could find out about a surgeon is to make sure the surgeon is board certified. And for this type of surgery, make sure they're board certified by the American Board of Plastic Surgery. There are non-plastic surgeons who offer this surgery, but their background training would not be as rigorous as a board-certified plastic surgeon.

Interviewer: And I guess the last question is what are some of the positive results that people see? Are most people happy with the procedure? What can a patient expect after they're all healed up and back to their lives?

Dr. Rockwell: Yes, I think universally the patients are happy. The extra skin is gone. The satisfaction is largely patient-derived where the abdomen is closed. There's not a lot of positive reinforcement from other people because other people aren't seeing it.

But the patient himself or herself just feels much better. Their confidence increases. They find clothing will fit differently. They can buy clothing more easily because they're more a standard size. And if exercise is an option, that extra skin, extra fat is not there, and just normal everyday moving around is easier and exercise is easier.

Interviewer: So if you've been on social media lately and follow any of those pimple popper videos or whatever, you may have heard of a ganglion cyst. It is a small bump that usually shows up on the hands or the joints. And online, they'll tell you to pierce it with a needle or hit it with a big old book. We're going to find out if that's the right way to treat these big old cysts.

Joining us today is Dr. Brad Rockwell. He is a professor of plastic surgery and he works with hands.

Now, Dr. Rockwell, when it comes to a ganglion cyst, what is it?

Dr. Rockwell: All of our joints have fluid inside that's somewhat similar to oil to keep the bones moving freely. And around the joint, there's a skin layer that keeps the fluid inside the joint. If that skin layer gets a little weak spot, it can form a bubble and the normal fluid that's in the joint can enter that bubble. It stretches out that skin lining and then the bubble can get bigger and bigger. And eventually, that bubble can work its way up to be visible beneath the skin. And that's a ganglion.

Interviewer: So it's not just when you see pimple popper videos or whatever online it's oil or it's trapped dermatological fluid. This is something that your joints need to function correctly.

Dr. Rockwell: Yes. It's just normal structures that have moved outside of the joint and usually form under the skin. But they still have an attachment to the joint.

Interviewer: Oh, wow. Okay. And do they only show up on the hands, or can they show up in any joint?

Dr. Rockwell: They can show up in any joint. There are some that are more common. Palm side of the wrist, the back of the wrist, or the end joint in the finger are common spots. But the back of the knee is another common spot where orthopedists would treat ganglions.

Interviewer: Now, is there anything in particular that causes them? Any cofactors or anything, or are some people just more predisposed to having these, some activities that they do?

Dr. Rockwell: Most of the joints, we don't know. They may, to some degree, be arthritis-related, but most of the ones in the hand at the wrist don't have a specific arthritic etiology. At the end joint on the finger, there's a definite arthritic etiology. There's, in general, a bone spur that's there. The bone spur rubs on that skin inside joint layer and weakens it and allows the bubble to form, which becomes the ganglion.

Interviewer: Now, is there a way to, say, identify that it is a kind of ganglion cyst or it's one of these joint fluids, not something else that you should probably not be popping anyway?

Dr. Rockwell: Most times a doctor could look and tell. In general, where a ganglion is there is not something else comparable that would be in the same spot.

For a patient, they may notice that it increases and decreases in size. It is normal joint fluid that's beneath a stretched-out joint lining skin layer. Occasionally, that lining that contains the fluid can weaken and develop a little hole and the fluid may escape from the ganglion, and then the fullness will go away. The fluid escapes under the skin and gets resorbed. There are no symptoms associated with that.

So if someone notices a mass over the joint that gets bigger and then gets smaller and gets bigger, that's going to be a ganglion.

Interviewer: All right. So we now know what these things are, where they come from. Now, I've seen some pretty gnarly videos on the internet. Why or why not should someone pop them or hit them with a book?

Dr. Rockwell: Well, deflating a ganglion in the end is a good treatment. There's a medically appropriate way to do it. Popping it at home or hitting it with a book to try to rupture that skin layer may accomplish the same endpoint, but the body won't necessarily see it as a friendly way to treat the ganglion.

So, in the office, rather than popping it, we will put a little needle into it and drain the fluid. So put some lidocaine in the skin to numb the skin, clean the skin well, and then put a needle in and drain the fluid out. And about 20% of the time, that will be successful in treating the ganglion.

Eighty percent of the time, unfortunately, the fluid will recur. And then it can be drained again, although most likely if it recurred once, it will recur again. If it recurs once, surgery is the best option to resect the ganglion down to the level of the joint.

Interviewer: What are some of the potential dangers of, say, doing it at home by yourself? It's not just a big pimple on the back. This is something that's connected to your joints.

Dr. Rockwell: Yes, exactly. It's a fluid-filled cavity that has a connection to the joint. So if it's popped at home and an infection develops in the ganglion, the infection has a very short direct route into the joint. And an infected joint would be a horrible outcome from ganglion treatment.

Interviewer: Geez. So say someone finds themselves with a ganglion cyst. They now know, "Hey, don't treat it at home." What kind of doctor should they be going to? Is this something that you go to a primary care physician, an InstaCare, a dermatologist?

Dr. Rockwell: So if it's in the hand, it should be a hand surgeon, and hand surgeons are either orthopedic-trained or plastic surgery-trained. If they're in other joints, most likely it would be an orthopedist.

Most of the other bigger joints in our body, the ganglion would be deeper under the skin or the patient may not actually know there is a ganglion there. But if they have arthritic trouble and are seeing a rheumatologist or an orthopedic surgeon for the arthritis, the doctor would recognize that the ganglion is there and then suggest appropriate treatment.