GLP-1s vs bariatric surgery: Does how you lose weight change the plastic surgery picture?

The road to significant weight loss is different for every patient. What works for one person doesn't always work for another. For some, diet and exercise changes are enough to help them burn fat, build muscle and shed pounds. For others, medications like the massively popular GLP-1 drugs or surgical options like bariatric surgery are the tools they need to see stubborn fat finally melt away. The why and how that a person loses weight are deeply personal and should never be points of judgment. However, the why and how of weight loss trigger an interesting question.

Does the way in which a patient loses significant weight matter? Does it matter for overall physical and mental health, and for how prepared the patient is for additional aesthetic procedures to address excess skin or changes in skin texture and quality? ASPS Member Surgeons Kristy Hamilton, MD, and Sara Dickie, MD, offer nuanced insights into the evolving landscape of weight loss and the innovations reshaping plastic surgery.

Bariatric surgery vs GLP-1 medications: The basics

Time for a crash course in major weight loss options. For the longest time, changes to diet and exercise or talking about calories in compared to calories out dominated the weight loss scene. That and fad diets that don't work. However, for patients where diet and exercise alone didn't work or for those with serious obesity-linked health concerns, bariatric surgery, or gastric bypass, was the leading surgical option for significant weight loss.

Bariatric surgery helps patients with a certain BMI or significant weight-related health conditions lose weight by physically limiting how much food they can consume or by reducing the body's ability to absorb fat and calories. For example, gastric bypass, one of the most common weight loss surgeries, alters the digestive tract by creating a small pouch from the stomach and connecting it directly to the small intestine. Food enters the small pouch, bypassing most of the stomach and limiting how much a patient can comfortably eat.

GLP-1 medications can also limit how much a patient consumes, but in a different way. First, this class of medications supports short-term weight loss by slowing gastric emptying. By slowing how quickly food moves from the stomach to the small intestine, these medications help people feel fuller longer, which helps them eat less. These medications also influence the brain, sending signals that reduce hunger.

In a nutshell, both bariatric surgeries and GLP-1 medications can help overweight or obese patients more quickly and efficiently shed a significant amount of weight. Each also carries its own complications and risk factors.

Plastic surgery as part of the weight loss picture

One complication of significant, rapid weight loss is excess, bothersome loose skin. Weight comes off quickly, but in many cases the skin doesn't bounce back the same way, leaving patients with loose, sagging skin or uncomfortable volume loss in certain areas of the body.

For many patients, the only "fix" is plastic surgery options, such as skin excision and body lift procedures, which can remove bothersome excess skin, tighten and sculpt specific areas of the body and reduce uncomfortable issues such as skin infections, chafing and irritation caused by loose skin.

Does how you lose weight change your plastic surgery options?

Skin quality can significantly affect aesthetic surgical procedures, which brings us back to the original question: Does how you lose weight make a difference when you follow up your weight loss results with plastic surgery?

"Because GLP-1 is relatively new to the market and the massive weight loss space, we lack the long-term data needed to truly compare outcomes with surgical weight loss," said Dr. Dickie. "Our experience with surgical weight loss has certainly directed and informed the treatment of GLP-1 patients, but when it comes to healing patterns, recovery, complications, etc., I think the jury is out until we have five to 10 years of data to really compare with the bariatric surgery population. That being said, I think there is plenty to say from an anecdotal standpoint!"

It's an important distinction to point out before digging into the debate. Roux-en-Y gastric bypass surgery has been around since at least the 1960s, with significant advancements in the 1990s. That amounts to decades of studies and information on the procedure, results and aftereffects. Although GLP-1 medications have been used for almost 20 years in diabetics, they have only been FDA-approved for weight loss since 2014, with newer medications and formulations gaining approval in 2021 and as recently as 2023.

One potential issue with bariatric surgery and GLP-1 medication for weight loss is whether either option affects skin quality.

"I would say that in general, I have not observed a difference in skin quality," said Dr. Dickie. "For patients on GLP-1s who have lost more than 100 pounds, I think the stretched, thin, almost denuded skin is the same: full of stretch marks, with lost elasticity and a very thin dermis. The main difference I see is patients who have lost less than 100 pounds, and these are patients who may not have been candidates for bariatric surgery because they were overweight or 'lower level' obese, and their skin was in better shape to begin with. GLP-1s opened up this ability to lose weight without surgery, and eligible patients went from tens of thousands to millions basically overnight. So, I think skin quality is more about the amount of weight lost rather than the way it was lost."

At least anecdotally, skin quality for weight loss patients seeking a lift or excess skin removal may depend more on the amount of weight lost than on how it was lost. In some cases, skin quality may not even be the first factor that a plastic surgeon considers before evaluating a patient for surgical options.

"The single most important distinction isn't actually the skin itself; it's whether the patient has lost any of their digestive tract," said Dr. Hamilton. "With a Roux-en-Y gastric bypass, the anatomy is permanently altered, and those patients can genuinely malabsorb the micronutrients we rely on for wound healing. That has real-world implications for surgery regarding wound-healing capacity. But with more modern bariatric surgery, sleeve gastrectomy, where no portion of the digestive tract is removed, malnutrition from an inability to absorb nutrients isn't the issue. For those patients, and for GLP-1 patients, it becomes a matter of making sure they're simply eating enough and getting appropriate nutrition through their diet and supplements prior to body contouring surgery."

Weight loss surgery also has an additional factor that patients may see as a complication to future plastic surgery options, and that involves scars left behind by the bariatric surgery itself.

"Most bariatric surgery is done laparoscopically," said Dr. Dickie. "Those scars don't tend to really impact body contouring. If there was a complication or the surgeon had to convert to an open procedure, then those scars can impact the cosmetic surgery because you can't always cut that skin or scar out; you may need to work with it in the field."

Differences between bariatric and GLP-1 patients

Are there distinct differences between patients losing weight with bariatric options and those on GLP-1 medications? Sure. Does that change how a plastic surgeon evaluates patient care? Not necessarily.

"Our goal is the same for everyone," said Dr. Hamilton. "We want the patient at their goal weight, whatever that is for them, and we want them nutritionally optimized before we operate, generally taking in at least 100 grams of protein a day, adjusted for their height and weight. What we've noticed with the GLP-1 medications is that because patients are eating so little, we can actually see some delayed wound healing there, too. So, working with a nutritionist or simply making sure a patient isn't in a starved state going into surgery is very, very important to minimize complications and ensure the best results."

Instead of evaluating how a patient lost weight, plastic surgeons focus on the patient as a whole person, understanding their journey and the issues or challenges that may be unique to them. That's not to say patients shouldn't be honest with their doctor about their previous medical history. It is also crucial to tell your plastic surgeon about all previous surgeries and current medications so they can provide appropriate care and guidance and reduce potential complications.

"When I consult a GLP-1 patient, I ask their weight and weight loss history and gauge how much of their body weight they have lost and compare it to their ideal weight and how close they are to that," said Dr. Dickie. "I ask how long they have maintained that weight and if they plan to continue GLP-1. Before heading to surgery, I want the patient to be on a maintenance dose for at least three months and to have not lost or gained weight for about two to three months at least. Ideally, it would be closer to half a year. If they have gone off their GLP-1, I recommend waiting four to six months to ensure they can maintain their weight."

Does the mental preparation change between patients?

Another, less discussed difference between bariatric patients and patients losing weight with GLP-1 medications isn't physical. It's mental.

Many patients who have undergone a bariatric procedure also went through a process to assess not only their physical health, but their mental health as well. Not only did most patients have to meet specific BMI guidelines or prove they had weight-related health issues, but they also had to undergo mental health screenings in many cases.

Hitting specific benchmarks was seen as vital to ensure patients could maintain a healthy lifestyle post-surgery, including exercise and proper nutrition. The nutritional point was especially significant because surgery alters how much food a person can consume and how the body absorbs nutrients.

Mental health evaluations are not a required component of gaining a GLP-1 medication prescription and are generally not something that accompanies an evaluation to gain access to the drug.

"The rigorous mental health evaluation before bariatric surgery was doing important work: It helped prepare patients to stick to their diet and activity goals afterward through their own mental fortitude," said Dr. Hamilton. "What we're now learning is that the GLP-1 medications appear to influence what patients describe as 'food noise,' the constant thinking about food, and may even affect other addictive patterns, from alcohol to one's overall relationship with eating. Because the medication seems to quiet that noise pharmacologically, patients often find it takes less mental effort to maintain a cleaner diet while they're on it. This observation has generated further study, so we will have more detailed information coming. Bariatric surgery alone doesn't have that direct effect on the brain. So, in a sense, the medication is now doing some of the work that intensive behavioral screening and preparation used to shoulder."

While GLP-1 medications may ease some of the mental burden around eating, surgeons say the shift away from bariatric surgery may also mean losing some of the structured, holistic support that once accompanied significant weight loss.

"Back in the bariatric days, everything was a lot more structured because of managed care and insurance authorizations mandating steps to coverage," said Dr. Dickie. "Maybe there was also more attention to a holistic management of the patient's nutritional status, mental health and overall well-being than we may be seeing with the GLP-1s, since it is now completely driven by patients as opposed to driven by healthcare systems."

No matter how a person chooses to lose weight, it helps to have a strong support system and a team of medical professionals in place who can help you navigate both the physical and mental effects of significant weight loss, not only for optimal results but also for overall health and wellness.

Does this mean bariatric surgeries are a relic of the past?

GLP-1 medications certainly seem to be doing the heavy lifting in modern-day weight loss. Does that mean this medication class will overshadow surgical weight loss options?

"Most bariatric patients are on GLP-1 to start," said Dr. Dickie. "Many bariatric patients I see had surgery years ago and started GLP-1 to actually achieve their goal weight, and so are on them after their bariatric surgery. I can't say for sure that bariatric surgery is dead, but those surgical starvation procedures carry major complication risks. They are also very complicated to reverse. The era certainly changed the world, but I think we are in a much better place with GLP-1s."

Any surgery inherently carries some risk and isn't an option for all patients.

"What we're seeing is that GLP-1s appear to be a lifetime medication for people losing massive amounts of weight, whereas bariatric surgery can, for some individuals, be one-and-done," said Dr. Hamilton. "Interestingly, some patients are now combining the two: an initial phase of weight loss from bariatric surgery, then supporting and continuing it with a GLP-1, or vice versa. But what's clear is that overall, less bariatric surgery is being performed, because many patients are choosing to start with medication first and seeing great success with it."

With proper medical guidance, lifestyle changes and support, GLP-1 medications may be the first line of defense for patients seeking to lose weight and live a healthier life. Without the recovery time and expense of surgery, these medications may also free up additional resources for patients who want to invest in plastic surgery options to remove excess skin and contour their new physique.

So, while how you lose weight may not be a major factor in whether you can opt for plastic surgery once you reach your weight loss goals, your individual weight loss journey can still be an important part of setting yourself up for plastic surgery success.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.