By Marisa Lawrence, MD
According to the Centers for Disease Control and Prevention, 36.5 percent of adults in the United States 2011-2014 are obese – a body mass index (BMI) greater than 30kg/m2. 1 Health effects include diabetes, coronary artery disease, hypertension, osteoarthritis, obstructive sleep apnea and deep venous thrombosis (DVT).
Severe obesity is a BMI above 35 kg/m2; morbid obesity is a BMI above 40 kg/m2.
The American Society of Bariatric and Metabolic Surgery reports 196,000 bariatric procedures in the United States in 2015.2 Many physicians will encounter post-bariatric surgery patients, so understanding their medical and psychological issues enable us to better care for them.
Patients undergoing weight loss surgery experience health benefits, but the skin envelope deflates throughout the body. Skin folds can cause poor hygiene, intertrigo, skin breakdown and functional impairment. Surgical recontouring can relieve these symptoms.
Such surgery improves quality of life, self-esteem and body image. 3 Therefore, post-bariatric plastic surgery has both reconstructive and aesthetic components.
Patient selection is important for satisfactory outcomes and minimal morbidity. The preoperative evaluation considers the bariatric procedure performed, BMI, comorbidities, nutritional deficiencies and psychological issues; all must be optimized prior to surgery.
Among 511 post–bariatric surgery body contouring cases, higher pre-bariatric surgery maximum BMI and higher BMI at presentation were associated with increased complications.4 The best candidates for extensive body contouring surgery after weight loss have a BMI below 30 kg/m2 and may have multiple procedures.5 Patients with a BMI between 30 and 35 kg/m2 are higher risk; surgical planning is individualized . Symptomatic patients with a BMI between 35 and 40 kg/m2 may have one functional operation, e.g.panniculectomy or reduction mammoplasty. Patients with a BMI above 40 kg/m2 need further weight loss unless symptoms are very severe.
Following bariatric surgery, weight typically decreases exponentially over three to six months and stabilizes after 15 to 18 months. Body contouring surgery is done after the weight has plateaued for three months or longer 6 – weight loss after body contouring surgery generally leads to continued skin deflation and patient dissatisfaction.
Nutritional deficiencies are common in this population. Roux-en-Y gastric bypass patients have malabsorption from a bypassed proximal small bowel. Caloric restriction and noncompliance with prescribed diets lead to malnutrition. Protein malnourishment can impact wound healing. Mal-absorbed vitamins include thiamine, vitamin D, calcium, iron, vitamin B12 and folate.7 Anemia may occur, associated with decreased iron and vitamin B12.8 Preoperative laboratory work up includes complete blood count, electrolytes, albumin and pre-albumin. Patients should increase their protein intake before surgery to 70-100 g/day. Supplemental iron, calcium, B12, folate and thiamine may be required.
Smokers should stop smoking one month before and one month after surgery.* Major body contouring surgery creates large tissue flaps; nicotine causes vasoconstriction, risking flap necrosis, infection and poor wound healing.9 Preoperative cessation of smoking is confirmed by urine cotinine tests; positive tests will delay surgery.
Patient also have many risk factors for venous thromboembolism (DVT): obesity, immobility, increasing age and venous varicosities. The overall DVT risk for body contouring surgery is 2.9-8.9 percent.10 A hematologist should see patients with histories of DVT, pulmonary embolism and hypercoagulable states for perioperative management. Intermittent pneumatic compression devices are placed before general anesthesia. Peri-operative unfractionated or low-molecular-weight heparin depends on the Caprini Risk Assessment Model.11
Patient expectations are discussed at the consultation – there will be visible scars and prolonged recovery times. Emotional stability and the patient’s support network are also evaluated. Up to 68.6 percent of bariatric surgery candidates have had a psychiatric disorder during their lifetime.12 Those with issues relating to body image and body dysmorphic disorder are less likely to be satisfied, so realistic expectations are discussed prior to scheduling surgery.
Up to 85 percent of post-bariatric patients desire body contouring, but only 12 percent to 21 percent actually have it.13 Many expect insurance to cover the cost. Insurance may cover panniculectomy, ventral hernia repair and breast reduction; patients can have cosmetic procedures performed at the same time to reduce the cosmetic costs.
Several variables affect the staging of procedures, including the patient’s personal goals, finances and insurance as well as the surgeon’s experience and operative team. Longer operating times increase complications; shorter operations and staging procedures appropriately mean less anesthetic time, blood loss and infection.14 The patient’s complaints and desires are the most important determinants of the first area of the body to approach.
The abdomen is of most concern; the hanging skin pannus overlaps the pubis, affecting hygiene. A panniculectomy removes this lower abdominal apron of skin and is often a functional operation, performed on significantly overweight patients who have skin irritation from hanging skin. This surgery reduces skin problems but not the abdominal contour. Traditional abdominoplasty excises redundant abdominal skin, plicates the rectus muscles, elevates the mons and repositions the umbilicus. (See Figure 1.) The belt lipectomy is a circumferential operation that excises hip and lower back rolls and elevates the buttocks. The lower body lift is similar, but incisions are lower and less conspicuous in clothing. (See Figure 2.)
Some patients have vertical and horizontal laxity, so a fleur-de-lis abdominoplasty is performed with a vertical midline incision in addition to the lower incision. (See Figure 3.) Gluteal augmentation may be combined with these procedures; many weight loss patients experience flatter buttocks with tissue deflation. Options include a de-epithelialized back flap using redundant skin, fat grafting or implants.
After massive weight loss, the female breast deflates. A breast lift, or mastopexy, rejuvenates the breasts by raising and reshaping them – lifting nipples, removing extra skin and repositioning breast tissue higher on the chest. Scars are around the nipple-areola complex, vertically from the areola to the inframammary fold and along the fold. Skin folds that extend laterally may be removed with an upper body lift, extending the inframammary fold incision to excise excess back skin. (See Figure 4.) Breast implants can be placed with the breast lift, but complication rates of 20 percent are reported.15
A brachioplasty, or arm lift, contours the excess skin and fat of the upper arm. (See Figure 5.) This involves an incision from the axilla to the elbow. If the deformity extends to the lateral chest wall, the incision may extend into the axilla with a Z-plasty and along the chest wall. Liposuction may be performed concomitantly. Scars are initially conspicuous; scar management with silicone cream and lasers improves their quality.
Thigh lifts remove excess thigh skin and fat to improve thigh appearance. (See Figure 6.) Patients with excess proximal tissue may need horizontal resection, leaving the scar along the groin and infra gluteal creases. Patients with excess tissue from groin to knee require a vertical scar down to the knee as well as the horizontal scar. Liposuction can help reduce the size of the thigh and can be performed three to six months before the thigh lift to allow skin retraction.
After dramatic weight loss, the face loses volume, soft tissues descend and the neck loosens and sags. A face and neck lift repositions the cheeks, corrects the jowls and removes the loose, sagging skin. Fat grafting restores facial volume. The incisions are inconspicuous around the ears, extending into the hair above and behind the ear. (See Figure 7.)
With the increase in bariatric surgery procedures, physicians will encounter patients with massive weight loss requesting body contouring procedures. With comprehensive evaluation of the patient’s weight loss, timing, medical comorbidities, and nutritional and psychological statuses, these operations can be performed safely, yielding satisfactory, life-altering results.
1. Centers for Disease Control and Prevention. Prevalence of obesity among adults and youth: United States 2011-2014. https://www.cdc.gov/obesity/data/adult.html
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