Ruins No. 1 from the series Half by Julia Kozerski. It was, by any measure, a great achievement. Even with surgical intervention, sustained weight loss depends on enormous discipline and huge, permanent changes in lifestyle and mental attitude. Sampson had lost an incredible 98 kilograms, the equivalent of a pro AFL or NRL player: a Matthew Pavlich or a Justin Hodges. Like anyone else in her position, she was sure she'd feel entirely different as a result. All the horrors of morbid obesity, she thought – the health problems, the social ostracism, the self-hatred, the loneliness – were behind her. "I thought losing so much weight would solve everything," she admits. "I thought my life would be forever rainbows and unicorns." As it turned out, nothing could have been further from the truth. "There was actually no joy in the weight loss," she says matter-of-factly. "None. Because of the skin. It's hard to believe, isn't it? I lost nearly 100 kilograms. But I didn't look any better. "In fact, I looked worse." Australians are getting fatter, faster, than virtually anyone else on the planet. Just last year, a study in the British medical journal, The Lancet, found that of 188 countries, our rates of obesity had risen by a truly massive (no pun intended) 81 per cent since 1980. (The only country to beat us was New Zealand, with a rise of 93 per cent). Today, 29 per cent of us – almost one in three, or 5.2 million – are not simply overweight, but officially obese. Most of us know how hard it is to shift even a few extra kilos. Losing a third, a half, even two-thirds of your body weight can be, physically, almost impossible. More and more, it happens only with the assistance of surgery – formerly lap bands, now usually gastric sleeves (a 75 per cent surgical reduction of the stomach, resulting in a sleeve-like remnant) or gastric bypasses (a surgical division of the stomach into two, with only a thumb-sized pouch receiving food). "Once you have a BMI [body mass index] greater than 40," says NSW bariatric surgeon Nick Williams, "the chances of you getting back into a healthy weight range purely through diet and exercise are, unfortunately, very small."

As more and more of us become dangerously overweight, more and more of us are opting for some form of surgery. And so more and more of us are joining the ranks of people like Sampson, and confronting a post-weight loss problem that has nothing to do with fat at all. Instead, it has everything to do with skin. When we lose weight – especially large amounts of weight – the skin that once contained all those extra kilos does not simply melt away. Skin elasticity does vary widely according to age and genetics, but in many cases of significant weight loss, patients are left with large amounts of excess skin. This excess is present whether we lose weight via surgery or by natural methods. In Sampson's case, the skin on her torso alone weighed about seven kilograms. "I had three sets of rolls on my back," she recalls, "and my breasts were like, 'Welcome to Ethiopia.' My vaginal and stomach areas were all overhanging. It was disgusting. I remember lying in a hotel pool once, and all the skin just floated up around me, as if I was lying in a lily pad. It was just hideous." "Extreme skin excess is a really big problem," agrees Steve Merten, a specialist plastic surgeon working in Sydney, and supervisor of plastic surgery training at the city's Concord Repatriation General Hospital and Macquarie University Hospital. "We all have those Biggest Loser weight loss shows in our heads that make us think that once people lose the weight, they'll just look like everybody else. But they don't: the skin can be extremely unsightly. That's why they always show contestants shirtless or in a bra and knickers when the series begins, but never once they start losing weight." I remember lying in a hotel pool once, and all the skin just floated up around me, as if I was lying in a lily pad. It was just hideous.

"The best analogy I have is that they're deflated," says David Morgan, a Melbourne-based specialist plastic surgeon and Victorian chair of the Australian Board of Plastic and Reconstructive surgery. "They're like a balloon that's been blown up, and as you let the air out, the rubber – or skin – never returns to being as tight and smooth as it once was. So you have this looseness." "It can be a substantial health problem in and of itself," adds Kevin Ho, specialist plastic surgeon and Director of Plastic Surgery Training at Sydney's Prince of Wales Hospital. "It rubs together across their stomachs and beneath their breasts; it gets irritated and smelly; it can create ulcers. In summer, they can't wear light clothing, they've got to tuck a towel under their breasts, things like that." It's also a significant psychological issue. "The whole thing can be very hard to come to grips with, because people have a strong sense of achievement about losing the weight," says Merten. "Yet they're left in this position where they're wearing compressing, binding garments under their clothes to hide the rolls; they're terribly embarrassed about their bodies; they find it very hard to have sexual relationships." This is certainly true of Sampson. Following her weight loss, she did meet a man. "I was 35, 67 kilograms, feeling life was wonderful," she recalls. "I met this guy, and he was fantastic, and the first time we had sex, the first couple of times ... ." She pauses, looking down at the table. "He ended up just saying, 'Look, I really like you, but I can't cope with this.' And that was so demoralising, so crushing, that it basically ended me." She pulls a face. "I haven't dated since." But it did have one positive outcome. It was after this profound, intimate rejection that she made the decision to investigate her options. "That's what made me realise I had to try to do something about this skin," she says.

There is all sorts of surgery to remove skin after weight loss. In fact, there is only surgery: no diet or exercise regimen will shift it. Collectively, this surgery is known as body contouring, which makes it sound like something that might happen at a luxurious health resort and involve mud wraps and massages. In fact, it's some of the longest, most physically demanding work in the plastics field, for surgeons and patients alike. "They're very hard work operations – probably the hardest," admits Merten. "You're solidly operating for six to 12 hours." It also carries risk: of bleeding and clotting complications, and of wound infection. Scarring is always significant. Nevertheless, as obesity numbers in Australia rise, and surgical procedures to aid weight loss increase, it's perhaps inevitable that the number of body contouring procedures will rise, too. There are four main body regions targeted. In descending order of priority for both men and women (anecdotally, about 85 per cent of body contouring patients are women), they are the stomach, the breasts, the legs and the arms. In each case, the fundamental goal is to cut off excess skin. A full circumferential body lift, for example – the biggest single operation within the body contouring field – is best envisioned as a process in which you cut two lines right around the body at lower rib and buttock height. Then you cut away all the skin in between: all the excess stomach and groin skin, all the mid-to-lower back skin. Jilly Sampson had a circumferential body lift in August 2013, 13 years after her lap band surgery. This seems a very long interval; but in fact, most surgeons demand some kind of cooling off period after weight loss and before body contouring. "I won't do surgery on a person if they've had their [lap] band altered within a year," says Ho. "You hear enough stories of people substituting five kilograms of vanilla ice-cream for food: people who are psychologically not ready for surgery." Sampson waited so long because, frankly, she couldn't afford the surgery earlier. Her three operations left her an estimated $60,000 out of pocket, even with top health cover. "I would have got less than $10,000 of that back from Medicare," she says. In theory, body contouring procedures are available on the public system; in practice, it's unusual for them not to be done privately. And, with some insurance companies now refusing to fund even bariatric surgery, despite its clear health benefits, patients' costs seem unlikely to fall.

In Sampson's case, her body lift required an eight-hour operation, and she needed five weeks off work to recover. The operation itself had some complications: she required five blood transfusions, and also suffered a haematoma after surgery. One of her transfusions led to complications of its own, with massive swelling in her arm. "Plus, I had four drains for two weeks. All very uncomfortable and painful." Recalling it now, however, she's upbeat. "I did get a fake belly button," she says, laughing. "It's slightly skewed. I sort of thought I wouldn't have one, and then I thought, 'Now that would freak someone out!' " She had a thigh lift the following January. "I was in hospital for a night, but I had the pressure bandages on for six weeks." Then, in September 2014, she had a combination back lift, arm lift, and breast augmentation. Here, skin that has dropped from the sternum and on the upper back is cut away, which realigns the breasts: this incision, about a hand's breadth from the armpit, meets the incision on the underside of the upper arm, where a strip of skin is cut away from the "tuck-shop arm" area. "I was resistant to the boob job," Sampson recalls. "I thought, 'Well, that's for superficial people.' " But in fact, body contouring often involves breast implants, to try to restore normal shape to the torso. "That last one was the most difficult for me. I couldn't use my hands for ages, because you lose the mobility of your arms. But there were no complications." So what are the results of body contouring surgery? What can patients expect? Is this, at last, the conclusion to the weight loss journey they've been hoping for?

Sitting in the coffee shop, Sampson pulls up one sleeve of her jumper. A thick, raised, dark brown scar, almost a centimetre wide, runs up her arm. It's the scar from her arm lift, and she has similar scars on her stomach, under her breasts, on her back (both upper and lower), and on both arms and both legs. "The holy grail for everybody is scarless wound healing," says David Morgan. "There's this myth that plastic surgeons are miracle workers and can make all scars just disappear ­- but the reality is that as soon as you cut the skin, you will have a scar. The question is always how visible is that scar going to be. And certainly we're skilled at putting them in places where they can be camouflaged or hidden. But most body contouring patients are very pragmatic. Having lived a life of being very heavy and having lost that weight, they look back from whence they've come. And the transformation for them is so significant that the scar is perfectly acceptable." Kevin Ho agrees. "Vanity is almost non-existent in my patient group," he says – and this is certainly the case with Sampson. "Ultimately, if it's going to be a choice between the saggy baggy elephant and the Bride of Frankenstein," she says, laughing, "I'll take the Bride of Frankenstein." The results of her operations, she says, have been almost universally positive. She can go to the beach, she can buy normal clothes, she can use public transport. "I love catching the bus now," she says excitedly. "It sounds so weird! But I love it. I sit, someone sits next to me, and it's fine! Or in that row of three where you get up for prams; I can sit in the middle, and I fit!" Nevertheless, she still struggles with the aftermath of obesity. "Even today, if I hear people laughing, I'll still look around and assume they're laughing at me. I still go into movies and theatres and planes and sit in an aisle seat. So I do sometimes find myself saying, 'Same shit, different dress size.' People think it changes your world, and it doesn't really. But I guess what's changed is my confidence; my self-esteem about my life." Work, she says, is great, and she's even hopeful about a relationship in the future. "That earlier experience was so humiliating, I guess it's taken a while to get over it," she admits. "And the scars still make me feel a bit hesitant."

But, on a day-to-day basis, she concludes, she barely thinks about her weight at all. And this, perhaps, is the ultimate goal – and the ultimate privilege – of this kind of surgery. "I don't want patients to look in the mirror and think, 'I had surgery,' " says Kevin Ho. "I want them to not think anything at all – just to go about their day. The way I see body contouring surgery is that it gives people the ability to forget. All that teasing as a child, all that not having friends, not being able to do this or that, being depressed, being, literally, an outcast. Hopefully, after surgery, they can just feel normal." And this is, in fact, what Jilly Sampson has enjoyed most about her new life. "Being invisible in crowds," she says, shaking her head and smiling. "Being anonymous. It's remarkable." 'You just go wrinkle wrinkle ... wrinkle!' Their lives changed beyond measure, other body contouring patients share their stories. ANTHONY FLETCHER

' Credit:James Brickwood In 2013, at 140kg, Anthony Fletcher (pictured) was so unwell he could barely climb the stairs to his own apartment. His weight gain began after an illness and a course of heavy antibiotics. "My life was really topsy turvy: I lost my house, my job. I ended up on heavy sedation and antidepressant drugs, one of the side-effects of which was weight gain. I was struggling to walk, or even bend over; I was diagnosed with arthritis, osteoporosis. It was the worst scenario you can imagine." After several visits to his GP, Fletcher began considering a lapband, but his bariatric surgeon told him he needed more drastic measures. "I had a gastric sleeve operation in 2013. They removed 70 per cent of my stomach. I told no one about it because I was so full of shame. Ashamed of the weight, and of being a loser. Got myself to the hospital, got myself home; dealt with the vomiting – all alone. I felt like I would never even have a friend." In the following three months, he lost more than 60kg – an average of more than 5kg a week. "And all my skin just dropped. One of the things I really noticed, as a male, was: no bottom! Totally bottomless. You just go wrinkle wrinkle ... wrinkle! As time went on I realised I might have to have the worst operation I'd ever seen on TV. And I did." Fletcher had a circumferential body lift last year. "I decided beforehand that this time it had to be different. I really had to reach out," he recalls. He was amazed by the response: his nutritionist, yoga instructor, and two personal trainers all became involved in his recovery. His trainers particularly were "real gifts" – one even came to visit him in hospital, where he spent nine days: his surgeon had to operate a second time to remove a blood clot the size of a football, because during his original operation, the surgical team dropped him.

Nonetheless, Fletcher has nothing but praise for his body contouring experience. "Losing weight was easy compared to getting rid of the skin. But this is a very human thing. You're taking on something where you really don't know what the end result will be. You're going through huge physical and emotional changes. But now I feel like, literally, I've been given the chance to have my life back." DAVID SEJEAN

"As far as I'm concerned, the scars are battle scars." Currency trader David Sejean is a big handsome man; well over six feet, dark skinned and dark eyed. Now 36, he lost almost 90kg, from 181.9kg to 93kg, following gastric sleeve surgery in 2010. Like Jilly Sampson, he had a circumferential body lift in November 2013, and then a thigh reduction in 2014, in which a long vertical incision is made on the inside of the leg, and the loose skin gathered and cut away. "I was depressed for 10 years, basically. I lost a career [as an opera singer] that I was completely committed to, and ended up running a pizza cafe. I used to make great pizzas, and eat the hell out of them! My problem was that I responded to my depression by eating. Hedonistic, mindless eating in front of the TV: spoon loaded while I was still chewing. I put on 80kg in a couple of years – I was literally eating myself to death. Eventually, I was diagnosed with depression, went on medication for a while, started having counselling, started reading." After his bariatric surgery, it took three years to get the weight off before Sejean's first body contouring surgery. "Un. Be. Liev. Able. Pain. Excruciating. That's my memory of the body lift. It was a big operation on a big guy, and it was so swollen, so much bleeding. But it ended up okay: my surgeon told me they were the best results he'd had on a male. I went to the gym and busted my arse beforehand, so he just had to chop the skin away. As far as I'm concerned, the scars are battle scars.

"The best things since the surgery? It is so unbelievably good not to have to ask for the extended seatbelt on the plane; all the skin meant I was still enormous, you know. Not to have to just shop at Target, Mr and Mrs Big, even after losing 90kg. To walk into a normal shop and try on a medium and say, 'Holy s***, this fits me.' There are still things that are a challenge – I have to work on my self-esteem. "I tried to start dating a girl, and I realised I wasn't ready. My physical changes were still a long way ahead of my self-worth, self-esteem changes; I couldn't do it. But none of it happens overnight; you've got to be patient, just be in the moment. I did buy myself a red convertible Mustang. 1969. It's a kind of promise to myself to the future. I want to be driving my children around in it one day." SALLY TIVOLI*

"Before you lose weight you're just a fat bastard. But now you're a saggy baggy freak." Like many women, Sally Tivoli, 63, put on her excess weight – about 30kg – after children. "I was working, I never really had time for myself – you know that syndrome. I'd lost quite a bit of weight two or three times, but it takes so much concentration, so much focus, I'd just put it back on again. In 2009 I finally admitted I couldn't control it, and had lapband surgery. It was really successful: I lost about 25kg, and it just took the worry about food completely out of my mind." A few years later, however, Tivoli admitted that she was still feeling hampered by her body. "I'd look in the mirror and think, 'Oh well, I've lost the weight, but I still look bloody awful.' I'd never even considered body contouring – I'd always thought I'd lose the weight and I'd be fine. But everything just hung down; and there was still a lot of weight, just in skin, to carry around. You can't run; your back aches, your shoulders, your arms – even your head. Sitting on planes and public transport was really hard. And I had to be really careful about hygiene: two showers a day, especially under my boobs. I'd have to wipe under there during the day: it was really difficult."

Tivoli is, at present, just eight days out of an abdominoplasty (an incision at the bikini line to remove abdominal skin overhang) and breast reduction; her wounds seem neat and healthy, and there have been no complications from her surgery. "This did seem frivolous, which it shouldn't do," she admits. "I told people about my bariatric surgery, but I haven't told anyone beyond my family about this. I think people would have been horrified, and tried to talk me out of it. But losing weight's only half the problem: what you're left with can be just as devastating, and terribly disappointing. And imagine, if I feel like this having lost 25kg: how must people feel who've lost 70 or 80kg? "I worry a bit about people out there who've lost huge amounts of weight, and whose bodies still look absolutely terrible," she confesses. "I worry about the mental state that's left them in – that it could be even worse than before. Before you lose weight you're just a fat bastard. But now you're a saggy baggy horrible looking freak. I think there are so many people out there who are still hiding their bodies after weight loss, you know? And how can people, especially young people – how can they live life like that?" KATE FOSTER*

"I felt like a liar, or a fraud – it was this weird sort of split identity feeling." Kate Foster is a health worker in the prison system. She had always struggled with her weight. "I'm half Italian," she laughs. "If you're happy, sad, angry, confused – you eat." In 2003, when her weight reached 110kg, she decided to have lapband surgery. In the following year, she lost 50kg: an average weight loss of a kilo a week.

"I was completely obsessed with the whole diet and exercise thing. In some ways it was fantastic, but the end results were very confronting. On one level everyone's telling you how fantastic you look. But I felt like I was advertising a Porsche, and underneath my clothes I was a Barina. Actually, when I went to the surgeon, he said, 'I can't believe, looking at you in your clothes, that that's what going on under there.' The problem for me was my tummy and boobs – all this saggy skin. I felt like a liar, or a fraud – it was this weird sort of split identity feeling." Foster had an abdominoplasty and breast augmentation in 2008. "I was so nervous about it, far more so than I'd been about the lap band: I think it was the thought of deliberately changing my body. And even though it was really successful, I had a kind of crisis afterwards. I got terribly depressed. Maybe it was the anticlimax; the loss of the project. Plus, I'd always said I'd go online and start dating and stuff like that afterwards, and suddenly I had no excuses! No skin to hide behind! It took a couple of years to work through that. "The biggest change for me is the sense of being comfortable in your skin; comfortable naked. I'd never had that feeling, ever. But now I can go skinny dipping with friends; partners are available – all that stuff. I still feel like exactly the same person – same values, same beliefs, same memories – but now there's no disconnect with the way I feel and how the world treats me [as there is when you're very large]; and no Porsche/Barina issue! I used to think, with sexual partners, that I had to explain all the scars. And then after a while I realised: people don't even notice." *Not their real names.