If you’re a fan of the television show The Biggest Loser—ok, yes, I watch almost every week—you will have noticed an interesting property of human skin. When we pack on the pounds, our skin stretches to accommodate the extra load. But when we lose weight, our skin doesn’t bounce back in the other direction quite so readily.

Ironically, the more successful a weight loss patient is, the more likely excess skin becomes a real issue. Unless the person is very young and has excellent skin tone, they may be headed for plastic surgery to complete their journey back from obesity.

Lest you think redundant skin is a simple aesthetic concern, let me assure you that the problems can run much deeper than that. Granted, it can be very disheartening to get back to a normal weight only to see rolls and flaps when you look in the mirror. One post-bariatric patient told me that having extra skin hanging around her newly slim body was almost worse than not having lost the weight at all.

But that extra skin can pose some significant life challenges. Many people find it interferes with the new, healthy lifestyle they’ve chosen. How can you jog with extra arm, belly or thigh skin jiggling with every move? How can you join a gym or swim club if you feel your physique is too unsightly to reveal to others?

Speaking of revealing yourself, many weight loss patients look forward to feeling more comfortable and confident in intimate relationships, as well they should. It’s common, however, to be held back by saggy skin. Both men and women are often embarrassed by the appearance of their chests (some women refer to their droopy breasts as “tube socks”). And in extreme cases low hanging belly skin can even get in the way of physical relations.

Another irony is that extra skin can make it even more difficult to find clothes to fit than it was before massive weight loss. What do you do if your lower half is now a size 6 but your muffin top—now mostly skin—has to be tucked in to a size 14? And if you can’t find ways to comfortably house skin you no longer need, you may have to deal with chafing and rashes that can be painful and become infected.

Indeed it seems almost unfair that people who fight their way back to a healthy weight often have this additional hurdle to cross. Many look at plastic surgery after weight loss very positively, though, as it has the power to mark their amazing achievement, to put the finishing touches on their new bodies.