Samantha Middleton, 38, was over 19 and a half stone when she started taking GLP-1s. “With any sort of exertion, I was getting breathless, and I had excruciating back pain,” she says. “It wasn’t vain – I just wanted to feel better”.

Her weight had become life-limiting: “I stopped going to places. I went to Edinburgh and the walk to the castle almost killed me – I was in so much pain.” Her work as a carer was affected, too. “It was a lot of walking, lifting and physical exertion. It was so painful I was having to take sick leave.”

GLP-1 medications turned Samantha’s life around – after a brief stint on Wegovy, which she says gave her “extreme stomach pains” [the manufacturers say side effects can include stomach pain, vomiting, diarrhea, and constipation] she started Mounjaro in July 2024 and by this January, had hit her “maintenance weight” of 10 stone.

However, she began to notice one particular, persistent side effect. “Every time I raised my arms, like when I was driving, or when I went to a concert and I was trying to dance, all I could see was my arms swinging out of the corner of my eye”. She felt limited again. “I like to expose my arms, because I’m covered in tattoos, but I was very self-conscious and stopped wearing sleeveless tops.”

One huge side effect of the seismic weight loss that millions of Britons are experiencing on GLP-1s is the loose skin that’s left behind. According to clinical research company IQVIA, an estimated 2.4 million Britons have been prescribed GLP-1s, but just 200,000 people are receiving it through the NHS over three years.

Samantha knew that despite a BMI in the “high forties and low fifties”, she had none of the comorbidities – like diabetes, high blood pressure or sleep apnoea – that would get her an NHS prescription. So she turned to an online pharmacy.

The rise of online arms-length pharmacies selling this medication means that many GLP-1 patients are not getting the correct support. A recent study from the University of Cambridge has found that many users of GLP-1s experience a lack of medical support while taking the medication, and experience deficiencies as a result.

Simon Mackey, consultant plastic, reconstructive and aesthetic surgeon at Benenden Hospital, has seen an uptick in patients seeking out skin removal. “My business personally has increased by about 60 per cent over the last 12 months,” says Mackey. “And I’d say that’s largely as a result of the incredible weight loss people are having with these medications”.

“I think the distribution of GLP-1s should be more carefully managed than it is,” he says. “People are essentially going to drug dealers and getting these things”.

Samantha got her Wegovy through a regulated online chemist but still “I felt like they didn’t give me all the information”. “Even when I got Mounjaro in-person, the only warnings were that it could potentially cause pancreatitis, or you may have issues with your gall bladder. But nothing really cosmetic [was mentioned], like loose skin.”

Although weight loss can bring important health benefits and may improve longevity, loose skin in areas such as the abdomen, arms, thighs and breasts can cause discomfort, inflammation or infection, as well as significant distress about appearance

“There is generally no NHS funding to remove excess skin, even when the surgery or medication that led to the weight loss was NHS-funded, which can leave patients in a difficult position,” says Mackey. “Prescribers, whether private or NHS, should therefore make sure patients understand these possible consequences and are psychologically prepared for them before starting treatment.

“With my patients, I use the analogy of a plastic bag,” explains Mackey, “So if you stretch a plastic bag a little bit and let go it will ping back, but if it goes beyond its elastic limit, it can’t. You get stretch marks, and whatever you do, it’s very difficult to shrink it back”.

Samantha attempted to tighten her skin: “I tried to increase my protein intake. I was trying weights. I bought all these creams that claimed to help with loose skin, and obviously they didn’t help.”

Working as a GP’s receptionist, she knew that getting cosmetic surgery on the NHS was unlikely. So she booked a £50 consultation with a local surgeon. The operation to reduce the skin on her arms cost £5,865. “I don’t have savings, and I don’t like taking bank loans. I was looking at credit cards, but luckily, my mum lent me money, and I’m paying her back”.

So what does the skin removal operation look like? Essentially it involves pulling skin taut, then cutting the excess off, before sewing it back together along a tighter line. The skin is always weighed after removal. “The maximum we’ve removed is close to 11kg, but for most people it’s about 2-4kg,” says Mackey.

Samantha found the process very simple: “I’ve got a scar that runs from my elbow to just into my armpit and it’s slightly red. I’m using silicone scar tape and factor 50 SPF, but I’ve been told it’ll take 18 months to heal fully.”

However, like all operations, it isn’t without risk. Paradoxically, those who may have lost the most weight could carry the most risk during operations like this. “When people have gained a significant amount of weight, their vessel size increases, so…the risks and complications of these procedures seem to increase significantly,” says Mackey.

In addition, studies have found that GLP-1 patients will often gain weight after stopping the medication, and if they have already had skin reduction surgery, they will be doing so over skin that is “poorer quality”, Mackey says. “In an ideal world with any of these procedures you need to have achieved your target weight, plateaued for six months,” Mackey argues.

Samantha’s own weight had levelled out for just five months before her operation in May. She says she “would do it all again in a heartbeat.. My confidence has shot through the roof”.

She wants other people on GLP-1s to not have to go through so much hassle. “I think it’s unfair that people cannot source GLP-1s and get skin removal surgery [on the NHS] if it’s causing enough of an impact. The NHS purports to say mental health is such an important part of people’s healthcare but doesn’t take cosmetic things seriously. Even though losing a lot of weight means I’m saving the NHS money in the long run.”