This 50 years-old female presented to Dr. Siamak Agha from Oregon. The patient weighed 490 pounds when she underwent a duodenal switch surgery. She subsequently lost 260 pounds and remained at a weight of 230 pounds for several years despite rigorous exercise on daily basis. When she presented to Dr. Agha in 2009, the patient weighed 230 pounds and her waist was 60 inches. A comprehensive plan of multiple procedures and stages was planned for her with a commitment that she will stay in Southern California to heal in between. Throughout the one year of her transformation, the patient lost a total of 70 pounds through surgery and exercise. As a result, she required redo of several of her procedures. During patient's last visit, she weighed 160 pounds. This is probably the most extreme plastic surgery transformation. Final total body lift pictures were taken in May 2011.