Tresnae Ramsey lost half her body weight while taking an obesity drug. It improved her health but left her with loose skin across her body. Photo / Cassidy Araiza, The New York Times
Obesity drugs are leaving more people with loose, sagging skin. But firming creams and body contouring treatments are largely a pipe dream, experts say.
In a little less than a year, Tresnae Ramsey lost 45kg on the obesity drug tirzepatide, but her skin bore the memory – sagging, drooping and pooling in soft folds. “When I sit down on the couch, I hear a ploop,” she said.
At first, it felt like a small price to pay because, as she lost weight, Ramsey’s endometriosis and fibromyalgia pain subsided, and her blood pressure and blood sugar levels normalised. But as her skin loosened and her breasts drooped, Ramsey, 37, grew more self-conscious, avoiding gyms, public pools and other places where her body would be on display.
Excess skin has long been an issue among patients who’ve had bariatric surgery, which makes the stomach smaller, or otherwise lost weight rapidly. But over the past few years, doctors say they’re seeing loose skin much more often as new obesity drugs – like Ozempic, Zepbound and Wegovy – become more powerful and commonplace.
One in eight adults in the United States now say they’ve taken these medications, fuelling demand for body contouring procedures that get rid of or firm up loose skin. But many of these services are prohibitively expensive, and the nonsurgical options – like ultrasound, radio-frequency and laser treatments – have largely not been studied after major weight loss. That mix of high cost and scant research has opened the door to a cottage industry of influencers peddling creams, collagen, supplements and other dubious remedies online.
“I thought I knew what weight loss would be like,” Ramsey said. “Nobody warned me about the loose skin.”
Collagen and elastin are proteins that give skin its firmness and elasticity. So skin will flex as you gain weight, build up muscle or become pregnant. But like a rubber band stretched for too long, it doesn’t always snap back.
When you lose weight, the fatty layer of your skin known as the hypodermis shrinks, leaving some empty space between your skin and muscle. “The skin has to go somewhere, and it usually goes down because of gravity,” said Dr Holly Lofton, an obesity medicine specialist at NYU Langone Health in New York City.
Sometimes, skin can retract to the body’s new contours, but that tends to happen only when people are young or lose a small amount of weight, she added.
When people lose at least 23kg or lose weight quickly, the skin can’t rebound as well. And after your mid-20s, collagen and elastin levels also start to decline, said Dr Heather Woolery-Lloyd, a Florida-based dermatologist.
“If your skin bounces back, you’re the lucky one,” she added.
For many people, loose skin can be troubling. The skin often rubs and slides against itself, and over time, that friction can cause rashes, chafing and even open sores, said Kayla Northam, a nurse practitioner specialising in obesity medicine at Massachusetts General Hospital. Sweat can also collect inside the skin folds, making patients prone to bacterial and yeast infections.
When Northam was 20, she lost 68kg with bariatric surgery. It was “tremendously successful,” Northam said, but the operation left her with loose skin – and a mix of emotions. She had cut her weight in half, but her skin would knock against her legs as she walked, or catch on her arms as she worked out. “It was just demoralising and very uncomfortable,” Northam said.
These physical challenges can ripple into emotional ones. One study showed that having more loose skin was associated with higher depression scores, said Valentina Ivezaj, a clinical psychologist at Yale School of Medicine. While research suggests that body dissatisfaction generally improves after significant weight loss, Ivezaj said that her patients occasionally reported feeling even worse because of loose skin. “Some patients will tell me that they felt much more confident in their larger body because they felt firm,” she added.
Ramsey has tried a dozen creams, lotions and moisturisers based on testimonials she has seen on TikTok and Instagram, hoping one of them will help restore her skin’s elasticity. While many companies market “firming” or “lifting” creams, experts say they don’t work deeply enough to tighten skin.
Moisturisers and hyaluronic acid can plump the skin so that it looks firmer, but they need to be used every day to continue seeing benefits. Similarly, creams with retinol or vitamin C can brighten skin and improve its texture, making it look more youthful and tighter, said Dr Edward Ross, director of the Scripps Clinic Laser and Cosmetic Dermatology Center. He said retinol – and the broader class of vitamin A-based products – was the single best thing for skin health. But when it comes to loose skin, any benefit is likely to be more aesthetic than structural, he said.
For collagen, the research is more complicated. Collagen creams probably won’t help tighten skin since they don’t change your skin at the biological level, Ross said. And while some studies suggest that collagen supplements can improve elasticity, hydration and wrinkling, a recent analysis of 23 trials found that only studies funded by the pharmaceutical industry showed these effects.
Experts say the best way to tighten skin on your own is by building muscle, since it can fill in the gap left behind by fat. While aerobic and resistance training can both be good options for improving skin elasticity, resistance training promotes more muscle growth. Influencers often tout eating more protein and drinking bone broth to maximise collagen intake, and while both can help build muscle, don’t expect them to actually increase the collagen in your skin, said Dr Jacqueline Watchmaker, a cosmetic dermatologist and laser medicine specialist based in Arizona.
In general, Northam recommends managing expectations, especially when influencers sell their own supplements or advertise quick fixes. “I think of it almost as snake oil salesmen,” she said.
For modest weight loss around 23kg or less, some dermatologists offer ultrasound and radio-frequency therapies – common brand names include Ultherapy, Sofwave and Thermage – which essentially heat up the skin’s connective tissue to stimulate collagen and elastin production.
They work best on the face and the neck, but “when you go down the body, they work less,” Watchmaker said, with minimal effects on the belly and thighs.
The results are also not immediate: it can take three to six months to see skin tighten after ultrasound and radio-frequency therapies. They also need to be repeated every six months to two years to continue seeing results, Watchmaker said.
Laser surfacing is another popular option, but it doesn’t actually tighten skin, she added. Instead, it smooths and improves wrinkles, making the skin look better, but it does not change its elasticity.
Experts say the only option to get rid of loose skin after major weight loss is skin removal surgery, trimming away the overhanging skin and tightening what remains. These procedures include face, arm, breast and thigh lifts, as well as tummy tucks and panniculectomies (to remove excess skin hanging from the belly), said Dr Lyle Leipziger, chief of plastic surgery at Long Island Jewish Medical Center. Patients need to be at a stable weight for at least six months to be good candidates for surgery.
Potential risks include bleeding, infections and wound management issues. And all of these operations leave lasting marks: “We trade skin for scar,” said Dr Joseph Khouri, a plastic surgeon at University Hospitals Cleveland Medical Center. Besides those from arm lifts, however, most scars can be hidden well, and many patients find the benefits worth it, Khouri said.
But these operations are rarely covered by insurance, unless patients can prove that they are “medically necessary” and that everything else they’ve tried has failed, he said. For most patients, the price tag – on average US$5000 to US$15,000 ($8500 to $25,500) – puts these surgeries out of reach.
Northam said she was only able to get surgery herself by living at home with her parents for a year to save money. A local hospital gave her a quote around US$30,000, but she found a surgeon two hours away who’d charge only US$12,000 to remove skin from her belly and thighs.
Ramsey has been considering skin removal surgery, but she’s held out so far, hoping that her skin will firm up on its own. She walks 2 miles every day, takes collagen supplements and meticulously applies “skin-tightening” creams and moisturisers. “It’s just knowing that I’m doing everything I can,” she said. “At least I’m trying.”
She isn’t sure if it’s her skin routine or simply the passage of time, but Ramsey says she’s grown more comfortable with her new body. “I wear my loose skin as a badge of pride – look what I was able to accomplish,” she said. “Look what I was able to go through.”
This article originally appeared in The New York Times.
Written by: Simar Bajaj
Photographs by: Cassidy Araiza
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