Does everyone go through this? Will the skin tighten up? I was overweight for more than 12 years. Am I going to end up needing surgical skin removal? Can you offer me any advice? I'm a medical student in the UK and my colleagues seem determined to proffer surgery as the only option."

There are 14 things you should know about loose skin after very large weight losses:

1. Skin is incredibly elastic. Your skin can stretch and expand or tighten and retract to a great degree. Look at what women go through during pregnancy. Some women do experience stretch marks after pregnancy, but obviously skin is remarkably elastic.

2. Elasticity of skin depends on both genetics and environment/lifestyle. Wrinkling and loss of elasticity is partly the consequence of aging (genetic factors) and also a result of environmental factors such as oxidative stress, excessive sun exposure, and nutritional deficiency. The environmental parts you can fix, the genetics and age part, you cannot. Advice: Get moving and change the things you have control over... Be realistic and don't worry about those things you don't have control over.

3. How much your skin returns to its former tautness depends partly on age. The older you get, the more an extremely large weight loss can leave loose skin that will not return to normal.

4. How long you carry extra weight may influence how much the skin will become taut after the weight loss: For example, compare a 9 month pregnancy with 9 years carrying 100 excess pounds.

5. How much weight was carried has a lot to do with how much the skin will resume a tight appearance. Your skin can only be stretched so much and be expected to "snap back" one hundred percent. With extreme obesity, the probability of there still being loose skin after weight loss is higher.

6. How fast the weight was gained also has a lot to do with how much the skin will resume a tight appearance. Your skin can only be stretched so quickly and be expected to "snap back."

7. How fast weight is lost also has a lot to do with how much the skin will tighten up. Rapid weight loss doesn't allow the skin time to slowly resume to normal. (This is yet another reason to lose fat slowly; 1-2 pounds per week, 3 pounds at the most if you have a lot of weight to lose, and even then, only if you are measuring body fat and you're certain it's fat you're losing, not lean tissue).

8. There are exceptions to all of the above; For example, people who gained and then lost incredible amounts of weight quickly at age 50 or 60, and their skin returned 100% to normal.

9. Creams probably don't work. There are many creams advertised as having the ability to restore the tightness of your skin. the late bodybuilding guru Dan duchaine used to recommend topical creams made with pycnogenol, which contain the antioxidant bio-flavanoids called proanthocyanidins. But to the best of my knowledge, none of the topical creams are scientifically validated. I haven't even heard much anecdotal evidence that they work -- at least not permanently and measurably -- and especially if you have a lot of loose skin. There are definitely some topicals that will pull water from under your skin, but remember, that is temporary. Buyer should beware with topical products. (as an aside, I've also heard anectodal reports that skin brushing was helpful, but again, I am not aware of any scientific evidence proving this is effective).

10. Nutrition has a lot to do with the health of your skin. Essential fatty acids in particular are very valuable for many reasons, and one of them is for the health of your skin. It would be worth taking an EFA supplement such as fish oil, flax oil or an oil blend like Udo's choice. Antioxidants are also very important, so be sure to consume copious amounts of a variety of vegetables and fruits. Also pay very close attention to hydration. Drink approximately a gallon of water a day or a minimum of half your body weight in ounces. (By the way, whey protein is high in a powerful antioxidant called glutathione).

11. Exercise has a lot to do with how your skin appears after you lose body fat. If you use very low calorie diets, you are likely to lose lean body mass, and this is going to exacerbate the loose, hanging skin appearance. On the other hand, if you are exercising regularly and increasing lean body mass with weight training, you will be more likely to minimize the appearance of loose skin.

12. Get second opinions if you are considering surgery. If you're considering surgical skin removal, consult a physician for advice because this is not a minor operation, but keep in mind that your plastic surgeon may be making his BMW payments with your abdominoplasty money. (Surgery might be recommended in situations where it's not 100% necessary). Surgery should be left as the absolute final option in extreme cases.

13. Give your skin time. Your skin will definitely get tighter as your body fat gets lower. I've seen and heard of many cases where the skin gradually tightened up, at least partially, after a one or two year period where the weight loss was maintained and exercise continued.

14. Know your body fat percentage before even thinking about surgery. Loose skin is one thing, but still having a lot of body fat is another. Be honest with yourself and do that by taking your body fat measurement. This can be done with skin fold calipers or a variety of other devices (calipers might not be the best method if you have large folds of loose skin. Look into impedance analysis, underwater weighing, DEXA or Bod Pod).

Suppose for example, a man drops from 35% body fat all the way down to 20%. He should be congratulated, but I would tell him, "Don't complain about loose skin yet, your body fat is still high. Press onward and keep getting leaner and be sure to focus on strength training to increase lean body mass as well."

Average body fat for men is in the mid teens (16% or so). Average body fat for women is in the 20-25% range. Good body fat for men is 10-12%, and single digits is extremely lean. Men shouldn't expect to look "ripped" with 100% tight skin on the abs unless they have single digit body fat. Women shouldn't expect to have tight abdominal skin unless they are in the low to mid teens in body fat.

Except in extreme cases, you are actually unlikely to see someone with loose skin who has very low body fat and especially someone who has not just "lost weight" but has altered body composition by adding lean muscle as well. It's quite remarkable how much your skin can tighten up once your body fat goes from "average" to "excellent" and even more so when lean body mass increase. Someone with legitimate single digit body fat and a ton of loose skin is a rare sight.

So the key to getting tighter skin is to improve your body composition (muscle to fat ratio), and lose more body fat, slowly and sensibly, up to the point where your body composition rating is BETTER than average (in the "good" to "great" category, not just "okay"). Only AFTER you reach your long term body fat percentage goal should you give thought to "excess skin removal." At that point, admittedly, there are bound to be a few isolated cases where surgery is necessary if you can't live with the amount of loose skin remaining.

However, unless you are really, really lean, it's difficult to get a clear picture of what is loose skin, what is just remaining body fat and how much further the skin will tighten up when the rest of the fat is lost.

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