Losing 165 pounds of fat was only half the battle. Pruning 15 pounds of excess skin proved to be nearly as long and arduous. It had to be done, though. "I looked like a Shar-Pei," said Laurie Crawford of Delaware.

Step one in her makeover: gastric-bypass surgery in March 2003.

Step two: plastic surgery to excise flaccid rolls of flesh left behind by her weight loss.

Crawford completed her transformation last year after two body-contouring procedures.

"I am done with the knife," she recently declared. The mother and homemaker, 44, dropped from 305 to 140 pounds. Just as important, she became more firm -- thanks to her skin-reduction operations. Body contouring after massive weight loss is one of the fastest-growing surgeries in the United States, according to the American Society of Plastic Surgeons. Crawford was among more than 68,000 Americans who had the work done last year -- a 22 percent rise from 2004. Ninety percent of the patients are women. The trend reflects the spike in bariatric (weight-loss) surgeries, which increased from 130,000 in 2000 to 170,000 last year. Dr. Bivik Shah of the Far East Side devotes almost half of his practice to bariatric patients.

His patient load at the Columbus Institute of Plastic Surgery has nearly doubled to two or three patients a week in four years.

"Bariatric surgery often is a two-step process," said Mary Beth Smith, his wife and a nurse at the institute.

"First, there is the gastric bypass; then you have to get rid of the excess skin."

Shah removed 10 pounds of skin from Crawford's arms, breasts and abdomen during seven hours of surgery in May. He took 5 more pounds of skin from her thighs and buttocks during a shorter surgery in December.

He also repositioned tissue, tightened muscles and removed fat to lift and tone her problem areas.

Shah takes 20 to 25 pounds of skin from his typical patient, removing more than 100 pounds in rare cases.

"These are long and complicated surgeries with some risks," he said.

While she lost nearly half her body weight, Crawford said, "My breasts sank down to my bellybutton."

Yet her decision was more than cosmetic: Friction from creases in her belly caused cysts and rashes, she said.

Risks from the skin surgery include infections, bleeding and blood clots. The recovery might require six weeks of relative inactivity. In addition, patients are frequently sent home from an overnight hospital stay with wraps and drainage tubes.

Long scars are inevitable from incisions that encircle the midsection or run the length of thighs and upper arms.

When cutting the abdomen, doctors risk detaching and losing the bellybutton.

Also, because of the dramatic weight loss involved, physiological changes subject bariatric patients to poor healing.

"They are riddled with complications," said plastic surgeon Christine Sullivan of the Sullivan Centre on Olentangy River Road near Powell.

"Their digestive system has changed, and they don't have the same immune system."

Nevertheless, Dr. Timothy Treece of Columbus Aesthetic and Plastic Surgery in Upper Arlington described his gastricbypass patients "as some of my happiest and most motivated. Not a day goes by when I don't have somebody in my office for this."

Contouring was "icing on the cake" for Kathleen Johnson, who lost 155 pounds and dropped 22 dress sizes after her gastric bypass four years ago.

The medical technologist from Plain City, in her "upper 50s," opted two years later for skin removal and a reshaping of her buttocks, thighs and abdomen.

"I didn't have big flaps of skin," she said, "but I had so much invested financially, physically and emotionally in this process that I wanted to finish it."

The buttocks were especially troublesome.

"I was sitting on folds of skin, and it hurt," she said.

Deformities vary by body type, fat-deposit patterns and amount of weight lost, according to the American Society of Plastic Surgeons.

Doctors tailor surgeries to patient needs and desires.

One other consideration: finances.

Insurance companies generally limit coverage to the abdomen, where medical problems such as ulcers might develop from creases in the skin.

"It's not uncommon for someone to spend $20,000 to get their body back in shape," Treece said.

Insurance paid for the skin removal from Johnson's abdomen.

Otherwise, "I paid for it all upfront," she said. "I waited until I saved enough money."

Many patients who commit themselves to gastric bypass overlook the possibility of body contouring.

"I had one patient who had more problems with her extra skin than when she was fat," Sullivan said. "She made me realize that these patients need better counseling. Some don't have a clue about the skin issues they might face."

Crawford turned to the Internet to learn about contouring.

"I was so focused on my weight loss, I hadn't even thought about it," she said. "I didn't realize that would be something I needed."

A bariatric support group introduced Johnson to the idea.

"A lady there already had the procedure, and she was my inspiration to pursue it," Johnson said.

Despite the risks, expense and hassle, the women don't regret having had it done -- even though their skin is scarred and remains a bit loose in some areas.

"I'm not 100 percent happy with my legs," Crawford said. "I still see some cheesy areas where there is cellulite. But you have to be realistic: This won't make you into a Barbie doll."