Bariatric surgery is a highly cost-effective way to lose life-changing amounts of weight but the NHS rarely removes the excess skin that is left behind. Desperate patients are now crowdfunding their operations while struggling with anxiety, depression and identity issues

When Haze Atkin passed the 32kg (5st) mark on her weight-loss programme, something strange began happening to her skin. First it grew softer. Then it grew emptier. By the time she had shed her 64th kilo, her body had shrunk so much that her loose skin needed to be folded into her clothes. Now, when Haze sits, a hovercraft of skin skirts her seat. When she takes a bath, her spare skin floats. In bed, her husband Chris accidentally rests an elbow on it; he cant always be sure where Haze ends. The edges of her have become mistakable.

To her childrens delight, Haze can wobble her skin and make it talk like a puppet. Sometimes her daughter holds out her hands like a set of scales and Haze places her stomach skin on them. She thinks it weighs a stone. It has become oddly plastic, so that Haze can gather it in her hands and stretch and shake it, fold and mould it. But the one thing she can never do with her skin is forget it.

Like many people with excess skin, Haze lost a lot of weight after bariatric surgery. In the 10 months following her gastric bypass an operation the NHS has come to see as highly cost-effective she shrunk from 149kg (23.5kg) to 70kg (11st). She met all her targets. Her surgeons called her a model patient. And yet, just when Haze should have felt she had achieved her goal, her skin held her back. The scales said she had reached the end of her journey, but the mirror told a different story.

Haze is one of the 9,325 UK patients who in 2013 underwent bariatric surgery on the NHS, according to statistics held by NHS Digital. The same year, NHS England reported that the price of keyhole bariatric surgery for diabetes patients with a BMI of 35, for instance, is recoverable in just 26 months. According to projections from the Department of Health, the cost to society and the economy of people being overweight and obese could increase to almost 50bn in 2050, so it is easy to see why bariatric procedures make financial sense. But is the surgery causing a different kind of health crisis? Is such massive weight loss MWL, as healthcare professionals call it solving one problem only to create a new one, a generation of weight-loss survivors tormented by anxiety and depression because they no longer fit their skin?

Haze has a simple message to the NHS. You dont just leave people half-done. Finish it.

The NHS does perform some skin removal operations. But the only mention of skin removal in all Nices recommendations is that a multidisciplinary bariatric team provide information on, or access to, plastic surgery (such as apronectomy) when appropriate (an apronectomy is a mini tummy tuck to remove the apron of skin that hangs over the pubic area). This provision varies hugely by region. In theory, a patient needs to show that skin removal surgery is a health rather than a cosmetic intervention.

In practice, the local clinical commissioning groups, which commission NHS healthcare, rarely approve such applications which is why crowdfunding websites are full of people who have lost massive amounts of weight and are desperate to remove their skin, even if it means posting explicit, naked or near-naked photographs that play to a sort of pornography of excess skin. Hazes page has raised 332 of the 6,600 she needs for surgery. She applied to the NHS she suffers from skin infections, anxiety and depression, and believes the extra weight exacerbates her fibromyalgia (she is registered disabled). But she was rejected.

So each week for the past four years she and Chris have laid aside 20 every spare penny towards the cost of the fleur de lis abdominoplasty on which Haze has set her heart. This double incision runs vertically and horizontally, and was part of the suite of operations carried out on the actor and TV presenter Lisa Riley in her documentary Lisa Rileys Baggy Body Club. The fleur de lis leaves a wound so severe that Rob Winterton, the cosmetic surgeon who performed it on Riley, says it is comparable to a 20 or 30% burn.

But for Haze, the surgery is the only way out of an unbearable predicament. At 30, she finds her skin so invasive, so mentally hard to deal with, every day I just want to cut it off myself. It invades my thoughts, my feelings, all the time. Every time I get dressed.

If you catch yourself in the mirror, Chris interjects. If I touch you wrong. If I roll on you. If I see you getting dressed.

Hazes skin is always on her mind which is not, of course, where skin is meant to be. Her daily life has evolved to make dozens of minute accommodations. She must wash carefully, lying down and stretching her skin out in order to clean and dry it thoroughly. Where the skin is folded, bacteria grows, she says. Dressing is a military operation. Everything is tucked away. And her relationship, the way she and Chris interact, has changed too.

Haze has gone from one kind of person to another, and the speed of her transformation has caught both her and Chris by surprise. You went from having a plus-size, curvy, full wife which you never had a problem with to suddenly this petite woman with hanging sacks of skin, Haze says to Chris, who is seated at her side. And it really threw you.

It was trying to remember who she is, Chris replies. Not mentally but physically. Its like, are you sure its you?

The pair have been married for 13 years. But the surgery, so hyper-efficient and cost-effective, has not given their emotions, their instincts, their bodies, time to adjust. Ill get there in the end, Chris says. Its because the process is so quick. Very shocking.

They had a small amount of savings, which Haze spent on a breast augmentation to save my sanity because she was so depressed by her new paper bag breasts. Even so, in their most intimate moments, Hazes skin still comes between them. If Im on top and I lean forward, she says, my stomach gets there first. She turns to Chris. You literally hold it back, she says, putting her hands at her narrow waist to demonstrate. To try and make you feel better, he nods, and they reach for each others hands.

Two further years of saving lie between Haze and Chris Atkin and the promised land of an operation so extensive that Winterton says it puts two and a half feet of scar on a patient. Providing, of course, that inflation does not outstrip them. But Paul Watling, 34, from Manchester, has barely a week to wait. Like Haze, he was rejected for the operation on the NHS after months of psycho-evaluation. He was trying to get along with his skin, to live with it, until last summer when he picked up a friend from hospital after body lift surgery.

The sight of his friend in his new skin made Paul see himself with unexpected clarity. At lunch with his mother and his girlfriend, Charlotte, I turned around and said: I need it. I just felt the time had come to put this part of my life to bed.

We are talking in a breakout area of Manchester Metropolitan University where Paul works as a night-time duty manager for halls of residence. While students amble down the corridor, Pauls voice quickens. This is it! Something that has been a negative aspect of my life for all my life is banished for ever.

The negative aspect of Pauls life began as a child with a tendency to overeat. At 22, he weighed 191kg (30st). He was offered a gastric bypass after doctors discovered a lung tumour (he was too fat to operate on) and this was in 2005 was promised that his excess skin would be removed on the NHS. However, by the time his weight had stabilised, he was turned down for the skin surgery. Depressed by what he saw in the mirror, the nipples that sagged far below his chest, the reams of spare stomach and undereye sacks that made him look permanently tired, Paul began to eat and drink heavily.

I thought: If Im going to look this bad, I may as well fill it out and just be the fat guy again, he says.

Over the next 10 years his weight rose as he ate to fill up his skin; a gastric bypass is only a tool to help with weight loss, and depends on adjustments to diet and exercise to work. While his stomach expanded, Paul kept telling himself: Im nowhere near as bad as I was. Then, last Christmas, he woke up after a binge and needed the bathroom. Looking down at the toilet bowl, he realised he couldnt see what he was doing; his stomach was too large. I thought, thats not normal. I dont remember that.

He was staying at a friends house, and his friends bathroom contained a set of scales, something Paul hadnt seen in a long time. He stepped on. I was like: Wow! This is insane! The scales said he weighed 162kg (25.5st). He found his friend in the kitchen. I took my shirt off and said: Take a photo. And I could see, in that photo, the 21-year-old me. I said: This has to stop.

He researched nutrition and exercise plans and began to adjust his diet and lift weights. After 11 months, in an entirely self-directed effort, he had lost 64kg (10st).

I feel better than I have ever felt in my life, Paul says. I feel great. But I dont look it. I look awful. While we talk, Pauls right arm disappears beneath the table to shield his stomach from passersby.

Im happier now with the way people treat me and it is a world of difference. But when I was bigger, I was happier with the way I looked. I was just a fat guy. Thats all I was. Yeah, people take the piss and are cruel but its there for everyone to see. This, he says, looking down to where he can feel his skin pulling over his belt line, is a hidden shame. Even the fat guys in the gym hang around in the dressing room. But Im ashamed. I sneak into the family room and lock the door.

Paul is troubled not only by his skin but also by the fact that it troubles him. Its a constant internal struggle for me. Why are you spending 10 grand on this? Its just appearance. Come on! You can rise above this. Of course, how you look shouldnt matter, he says, but it does matter, because of the experiences you had when you were younger, the years of verbal and physical abuse. He is a heavy metal fanand has always identified as an outsider, found comfort in it. But his skin has made him feel more privately misplaced, estranged in a way that is unfamiliar he has become an outsider in his own body.

I know I should be proud of my excess skin. It should be a battle scar But the flip side, which is the stronger side that always wins, is: Look at the state of you, youre gross, youre disgusting, you cant let anyone see you I dont want to fit in with society, I want to fit in with myself.

Paul is right that not everyone with excess skin feels as he does. Krystina Wright, 31, from Grendon in Warwickshire, lost 44kg (7st) with the help of Slimming World, and has a pouch at her stomach.

She knows she has undergone a transformation, and that her skin tells the story of it. Last year she was shortlisted for Slimming Worlds woman of the year. Out dress shopping, she stood in the fitting room in her underwear, and her mum remarked, You can see youve lost weight. But I never see that in the mirror, Krystina says. When Im walking, [the skin] around my legs is obviously looser than somebody who hasnt lost weight but I just ignore it. Im so happy with my journey that everything negative about my old self doesnt seem to matter.

Even in her contentment, however, Krystina still associates the experience of being fat with an old self, and it is this sense of disjuncture between an old self and a new self, a fat self and a thin self, that challenges people who have lost a transformative amount of weight.

Skin is a boundary between ourselves and the outside world. But for Haze Atkin, her skin, in its looseness, provides an untrue border; her skin seems to stop beyond her true edges. Instead, she strongly demarcates the line between old and new selves. When she was fat, she was Hayley. Two years ago, after weight loss, she changed her name legally. Its weird to see pictures of me before, she says. You cant I cant tie those two people together.

Im very proud of Hayley. But thats not me. Theres a real separation. She picks up her stomach. The thing thats hanging on is this. Hayleys skin.

Elna Baker can relate to Hazes divided self. The American writer and performer, 35, has documented her weight loss and skin removal surgery in blogs and podcasts such as This American Life. Between losing weight (nearly 50kg/8st) and losing the skin, she lived in the same sort of limbo as Haze she thinks of it now as a transitional place between fat and this idea of thin.

But Baker also says she has travelled further along the timeline I dont know how to explain it. But theres, like, a core thing that youre still running from, she says, speaking on the phone from New York. And not to sound ungrateful for the means and the experience of getting to transform, but I also feel its more complicated than I expected, because its about identity and gender and worth. The thing that still saddens me is that I lived too long in the world as a fat woman to forget the way the world exists when youre fat. So now I feel like Im wearing a disguise, which allows me not to have to experience on a daily basis judgment, shame and hatred. But I also have all this muscle memory of that. So I sometimes feel confused like Im still experiencing a side-effect of a thing I no longer am.

Baker had implants to return her breasts to their former size, a body lift, a thigh lift and a circumferential body lift a cut around the circumference of the body. The scar draws a line between her top half and bottom half and has left her feeling, literally, a little divided.

Despite complications afterwards that meant that she had to pack her wounds with gauze, pushing wads into the holes left by burst stitches as if she were stuffing a soft toy, Baker is glad that she had the operations. But she has spent the past year using therapy, meditation and self-help to address the boundary between old Elna and new Elna. She hopes the division is an illusion and it is possible to reach into the depths of me and meet the person [I was] and integrate it.

Haze, meanwhile, hopes for the opposite, that surgery will not only make her proud of her body but sever her from the past. And Paul, only a week away from his operation, sometimes has to quiet the small voice that asks: What if I go through this and Im still not happy? He reminds himself: Ive set this up in my mind. This is closure of a lifetime of not being happy in my body.

All he, and Haze and anyone, really want is to be comfortable in their own skin.

• Find more information on weight-loss surgery at wlsinfo.org.uk

Read more: https://www.theguardian.com/lifeandstyle/2018/jan/02/i-want-to-cut-it-off-weight-loss-patients-excess-skin