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These cases are the most difficult. This 43 year old white male has undergone massive weight loss (> 150 lbs) following gastric bypass. A large quantity of skin and fat are removed to eliminate a large hanging fold (‘pannus’). The lower abdominal scar needs to be very long if not circumferential since the excess of tissue is present laterally as well as centrally. The surgery is done to eliminate hygiene problems as well as to improve the aesthetic appearance.