"If you looked at me with my clothes on, I looked fine," said Brown, now a 30-year-old triathlete. "But if I took my pants off, I looked like a shar-pei."

More than 170,000 morbidly obese Americans had major weight loss surgery in 2005, up more than 130,000 in five years. But lost in the hype over miraculous body makeovers is the fact that gastric bypass is often only the beginning.

With the precipitous increase in what's known as bariatric surgeries has come an equally large increase in what, for many, are the extensive and expensive second, third and, in rare cases, fourth body contouring surgeries necessary to bring the body back into shape.

"With most patients you're talking two, three, four stages of surgery, depending on what they need," said Dallas plastic surgeon Jeff Kenkel, chairman of the post-bariatric surgery task force for the American Society of Plastic Surgeons. "You're probably talking about a four- to five-year process from having the bariatric surgery, losing the weight over one or two years, and then completing the body contouring, which can be another couple of years."

At its most basic, body contouring involves cutting away sheaves of loose skin to perform any number of "lifts": face, thighs, breasts, upper arms, neck, buttocks, stomach, lower-body or even whole-body lifts.

Overall, body contouring procedures nationally have increased 77 percent between 2000 and 2004, the most recent year for which statistics are available. Although current numbers are unavailable, the American Society of Plastic Surgeons estimates that the 106,000 body contouring procedures conducted in 2004 are a tiny number compared with now.

The trend, active nearly everywhere, is driven almost exclusively by massive weight loss surgeries. Of the 106,000 body contouring surgeries in 2004, close to 56,000 were because of massive weight loss alone. Between 2003 and 2004, upper arm lifts increased 57 percent. Thigh lifts were up 61 percent.

"I'm seeing several new patients every week who have lost anywhere from 75 to 250 pounds," said Richard Korentager, a plastic surgeon at Shawnee Mission Medical Center.

Jeffrey Dillow, an Overland Park, Kan., plastic surgeon, said body contouring surgeries in his practice have increased 50 percent in four years.

To be sure, patients contemplating massive weight loss surgery are not left unawares. For most severely obese people, the bariatric surgery is not cosmetic, it's lifesaving. In general, any discussion of massive weight loss surgery typically includes pre- and post-psychological counseling, nutritional counseling and discussion of future body contouring.

"I'm very upfront about it," said physician Stan Hoehn, a surgeon at the Bariatric Center of Kansas City. "It is a matter of fact: If you lose 150 pounds from an elastic organ such as skin, you're going to have saggy skin."

"You have skin hanging around everywhere," said Gretencord, who underwent body contouring in May. "You don't want to wear short-sleeved shirts, or shorts. Even though you have lost all this weight, you feel very fat."

Massive weight loss surgery comes in three types: restrictive, malabsorptive or a combination. Restrictive reduces the size of the stomach, and thus food intake, using sutures or an inflatable silicone ring (Lap-Band). Malabsorptive entails rearranging the intestines to reduce the absorption of calories.

For some patients whose hanging skin causes severe rashes, ulcers or infections, insurance sometimes pays part. As with all major surgeries, the procedure involves just as many potentially serious risks.

"Mine was a seven-hour procedure," Gretencord said of her lower-body lift done by Dillow. "He actually took about 10 pounds of skin. Then he did extensive liposuction down in my legs and back and stomach and thighs. I went from a size 14 to a size 8/10 just from the body contouring."

After surgery, patients often return home with drainage tubes, wear elastic garments and must limit their activity for weeks, requiring vacation or short-term disability time.

"You have to have realistic expectations on what your body is going to look like," Gretencord said. "You're going to have surgical scars. You're not going to look like a model. You have to know what you want when you go in."

Brown's take: "I did seven triathlons last year, and I hadn't been on a bike in 15 years. I still sometimes think of myself as the fat girl. But when I look in the mirror and see who's looking back, I'm startled. Pleased, quite pleased, but startled."

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