A Collaborative Approach to Reconstructive Surgery: The Importance of a Supportive Team

| March 6, 2009

by Tracy Martinez, RN, BSN, CBN; Christopher D. Still, FACN, FACP;
MK Batra, MD, FACS; and RJ Nelson, BS

Part 1: The IMPORTANTCE OF A SUPPORTIVE TEAM

by Tracy Martinez, RN, BSN, CBN

When patients seek bariatric surgery to treat their disease of morbid obesity, they also seek support and education to help them throughout their entire process. Patients who have lost significant weight following bariatric surgery will often inquire about reconstructive surgery from their bariatric team. For this reason, it is important that the clinicians in your program have adequate and accurate knowledge to guide them. Dr. Christopher Still, a well-known internist and bariatrician, Dr. Munish Batra, a board-certified plastic surgeon with substantial experience in post-massive weight loss reconstructive surgery, and I will discuss important considerations when working with patients seeking reconstructive surgery.

According to the American Society for Metabolic and Bariatric Surgery (ASMBS), there were 205,000 bariatric procedures performed in the United States in 2007. Table 1
(from the American Society of Plastic Surgeons [ASPS]) shows that in 2007, 66,947 Americans underwent reconstructive procedures following massive weight loss. This is an increase from the previous year, which was a total of 65,945 procedures performed. Data from the American Society for Aesthetic Plastic Surgery (ASAPS) shows that since 1997, surgical procedures have increased 142 percent. With an increase in both bariatric procedures and reconstructive procedures, it seems prudent to educate your multidisciplinary team members in order to enhance their knowledge so that they can be a resource for their patients.

In our program, we call reconstructive surgery reward surgery. We do not want patients to feel embarrassed or vain for seeking reconstructive surgery. On the contrary, we discuss the possible desire or medical need for reconstructive surgery following massive weight loss at our preoperative education seminars. We stress the importance of their commitment to maintain a healthy lifestyle (daily exercise and proper nutrition) and wait approximately one year following bariatric surgery with 3 to 6 months of weight maintenance to prevent a false plateau. Several studies have shown that patients experience an improved quality of life and body image when body contouring surgery is performed following bariatric surgery.[2]

Suggestions to implement in your program

Inform. Inform patients early of the potential need for reconstructive surgery following extensive weight loss. This can be done at preoperative information sessions and reinforced in supportive educational literature. This helps ensure a thorough informed consent and prepares the patient for after surgery.

Referral base. Build a referral base of qualified board-certified plastic surgeons. In my experience, there is a significant aesthetic difference in postoperative results from not only procedures performed by board-certified plastic surgeons, but also those who have had specialized training or extensive experience in operating on individuals with massive weight loss. Make sure you have seen the postoperative results of a surgeon prior to your recommendation.

Educate. Please educate your patients on the importance of finding a qualified surgeon. It may be beneficial to have referral cards for them to help facilitate the consult. Obviously, qualifications are the most important consideration, but there are commonly variations of surgical fees. Unfortunately, most insurance companies do not cover reconstructive surgery. Panniculectomies may be covered by insurance for medical reasons, but symptoms of the side effects must be documented at each follow-up appointment, including any rashes, ulceration, dermatitis, infections, and balance issues from hanging redundant skin, for example. There are several opportunities that your program can provide to facilitate patient education. One is to invite a plastic surgeon whom you have worked with to a support group meeting. This gives the patients an opportunity to get educated in a non-intimidating way. Another is to offer a plastic surgeon the opportunity to write an article for your program newsletter. It may also be beneficial to coordinate an in-service for your program staff from the surgeon or surgeons you have identified as qualified to be a referral for your patients. Always make sure you have seen and have been satisfied with the preoperative preparedness, postoperative care, and results of the surgeon before they become a referral from your program. Your program fitness coordinator and clinical staff should reinforce the importance of exercise so the individual preparing for reconstructive surgery understands that achieving good physical condition plays a role in maximizing their surgical outcomes. Being in good physical condition helps the patient recover from the procedure better. A healthy body composition can maximize their aesthetic outcome both short and long term.

Reinforcing optimal nutrition. Doing this is key for proper healing. The program nutritionist should continue to emphasize the long-term commitment to proper nutrition, hydration, and vitamin supplementation. Adequate protein is important for wound healing, which is imperative after reconstructive surgery for a good postoperative result. (The next section on nutrition will elaborate on this in more detail.) Iron supplementation before surgery should be considered for the individual undergoing an abdominoplasty, for instance, since blood loss is not unusual. The basic preoperative laboratory assessment, including prealbumin, hemoglobin, iron, calcium, magnesium, and phosphorus should be considered.[3]

Psychological support. Lastly, but extremely important to patient care, is the role of psychological support. A consult with the program psychologist can be extremely valuable. A preoperative consult may help experts evaluate the expectations (both realistic and unrealistic) the patient holds with regards to the surgical outcome. It goes without saying that identifying the possible misconceptions or unrealistic expectations preoperatively can help prevent a lot of misery for everyone postoperatively. Many postoperative bariatric patients are probably highly motivated to undergo body contouring. High levels of motivation may not equate with psychological appropriateness. It is extremely important to match the patient’s expectations with potential outcomes and rule out body dysmorphia.[4] This distinction takes an expert. Encouraging a psychological consult can be a prudent and caring intervention by the integrative team.

Part 2: NUTRITIONAL ASSESSMENT OF THE PERSPECTIVE BODY CONTOURING PATIENT

by Christopher D. Still, FACN, FACP; and Tatiana Figueredo, MD, Center for Nutrition and Weight Management, Geisinger Medical Center, Danville, Pennsylvania

Introduction 
Depending on which surgical procedure performed, post-bariatric surgery patients may be susceptible to a wide variety of nutritional deficiencies that plastic surgeons and other health care providers should be cognizant of before embarking on any other plastic surgical procedure. The two most common bariatric surgeries being performed in the United States are the Laparoscopic Adjustable Band (restrictive) and the Roux-en-Y gastric bypass (combined restrictive/malabsorptive). Since restrictive procedures create a small gastric pouch for early satiety and normal absorptive surfaces remains in place, nutrient deficiencies are uncommon. In the gastric bypass, and to a greater degree the biliopancreatic diversion (with or without duodenal switch), because of their alteration of GI tract affecting normal digestion and assimilation of nutrients and calories, macronutrients and micronutrients, deficiencies are common and should be assessed. Similar to preoperative bariatric surgery nutritional assessment, a thorough evaluation and, if required, supplementation is recommended for perspective body contouring patients. This will provide the opportunity to replete any deficiencies caused by the primary bariatric surgical procedure, but also optimize wound healing.

Protein Calorie Malnutrition
Protein. Protein calorie malnutrition after bariatric surgery, as evidence by low-serum albumin/prealbumin serum level, is not uncommon.[5] Several studies have documented inadequate protein consumption up to 18 months after bariatric surgery.[6, 7] This can be due to a wide variety of reasons, ranging from changes in food preferences/tolerances,[8, 9] such as red meat and other animal proteins, and alterations in digestion as evidenced by reduced availability of pepsin, renin, and hydrochloric acid, which all may limit protein digestion.[7] The most sensitive screening for protein deficiency is a serum prealbumin. Serum albumin, an acute phase protein, can be decreased due to a variety of metabolic stressors, or over-hydration irrespective of nutritional status. The protein intake goal for patients contemplating plastic surgery should average 80 to 100g of protein per day. Although there are many types of protein supplements available for patients’ consumption, the best protein is classified as having the highest biological value protein. Products with amino acids in the hydrolyzed form are most commonly considered the most optimal. Adequate protein intake as reflected by a normal serum albumin/prealbumin levels should be obtained for at least four weeks prior to a body contouring procedure. This will hopefully decrease the amount of edema that can ensue from hypoalbuminemic states.

Vitamins and Mineral Deficiencies
Vitamins A, E, C, and K are instrumental in wound healing after body contouring surgery. Levels of B vitamins (thiamine-B1, cyanocobalamin-B12, and folate) can also be decreased following bariatric surgery and therefore should be accessed. Vitamins function as vital co-enzymes or co-factors in metabolic pathways involved in macronutrient metabolism as well as in oxidation/reduction reactions, hormones, or antioxidants.[10] The trace elements that are required for adequate wound healing include; copper, magnesium, iron, and zinc. Although not necessarily important in wound healing, calcium and vitamin D assessment and supplementation is also recommended given the recent study showing the high prevalence of deficiencies.[8,11] Any deficiencies in vitamin, minerals, or trace elements should be reversed for proper wound healing to proceed.[12]

Vitamin A. Vitamin A is a fat-soluble vitamin that can be depleted in times of metabolic stress or infection. It is important in collagen synthesis, immune response, and cellular adhesiveness. Decreased levels of vitamin A result in decreased in collagen production, delayed wound healing and, a predisposition to infection.[13] The recommended daily allowance of vitamin A is approximately 2,500 IU,[14] although this amount may need to be adjusted in gastric bypass patients given their altered anatomy/absorption.

Vitamin C. Vitamin C (ascorbic acid) is an important water-soluble vitamin, which functions a co-factor in the formation of collagen. Deficiencies are not uncommon in the post-bariatric surgery patient[15] and, if present, can decrease the rate of the hydroxylation process leading to delays in wound healing.[16] The recommended dietary allowance of vitamin C is 60mg per day, and the effects of vitamin C deficiency can be reversed with the administration of 100 to 1,000mg per day.[14]

Vitamin B12 and folate. Vitamin B12 and folate deficiencies occur most often in Roux-en-Y gastric bypass patients, although other malabsorptive procedures can also increase risk.[17] Unlike the other nutrients, absorption of dietary vitamin B12 is a complex process that requires an intact stomach, coordinated pancreatic enzyme release, and an adequate length of terminal ileum.[5] It plays an important role in DNA synthesis and neurologic function. It can cause megaloblastic anemia, weakness, depression, and a generalized peripheral neuropathy. Following gastric bypass, patients typically are supplemented with 500 to 600µg daily. Deficient patients may require intramuscular injection of 1,000µg monthly; until liver stores are replenished.[18] Folate is an essential water-soluble vitamin that is also commonly low after gastric bypass. In addition to its role in preventing neural tube defects, it is required for erythrocyte formation and maturation and can also lead to a megaloblastic anemia. Therefore, supplementation of both vitamin B12 and folate is suggested to prevent or treat such anemic patients. Folate deficiency is readily prevented with a minimum of 400µg of daily supplementation,[19] typically the amount contained in a multivitamin.

Vitamin B1 (Thiamine). Thiamine is a water-soluble coenzyme that plays a key role in carbohydrate metabolism. Although thiamine is not necessarily essential for adequate wound healing after plastic surgery, thiamine deficiency can lead to Wernicke-Korsakoff’s encephalopathy with resultant irreversible pontine cerebellar CVA and death. Its stores, which only usually last 3 to 6 weeks, can be depleted with any patients undergoing gastric surgery and more rapidly by patients experiencing postoperative nausea and vomiting. Thiamine deficiency is characterized by nystagmus, ataxia, memory loss, progressive paralysis, coma, and death. While easily corrected with early thiamin supplementation, surgeons and health care providers often supplement with B12—not considering thiamin deficiency —which is of no benefit in this life-threatening situation. If thiamin deficiency is suspected, prompt treatment of 100mg of thiamin intravenously or intramuscular in no IV access available, and continuing with 100mg every eight hours until resolution of symptoms then 100mg by mouth daily.[20] Patients are susceptible to thiamin deficiency after plastic surgery as well, given their altered gastric anatomy and therefore, plastic surgeons should be cognizant of the signs and symptoms.

Vitamin E. Vitamin E is another lipid-soluble, antioxidant, vitamin also known as alpha tocopherol. It exhibits anti-inflammatory property that acts as a cellular membrane-stabilizing agent by inhibiting the spread of lipid peroxidation.[21] When applied topically, however, vitamin E inhibits wound healing by reducing the number of fibroblast and collagen synthesis,[22] thus decreasing the scar tensile strength in an unacceptable scar. Vitamin E deficiency is uncommon after most weight loss operations and has not been shown to be clinically significant in patients who receive routine vitamin supplementation.[23]

Vitamin K. Vitamin K is essential in the production of prothrombin and in the carboxylation of glutamate in the clotting factors II, VII, IX, and X.[24] Warfarin, which causes disruption in the clotting cascade, often requires reversal before undergoing body contouring surgery.

Copper and magnesium. Copper deficiency is found most often following bariatric surgery and patients who receive total parenteral nutrition (TPN) without copper supplementation.[25] After body contouring surgery however, copper is an essential part of the metalloenzyme lysyl oxidase process. It allows for the oxidation for the lysyl residues on collagen, resulting in greater scar strength.[24] Magnesium is important to the enzymes responsible for collagen synthetic.[26]

Zinc. Zinc is an essential trace mineral required for cellular growth and replication. In post-bariatric surgery patients, zinc deficiency is often sub-clinical and often manifests itself as hair thinning and loss.[27] Severe zinc deficiency however, can result in skin changes, mouth ulcers, ataxia, poor appetite, diarrhea, alopecia, cell-mediated immune disorders, and overall delay in wound healing.[28] The RDA of zinc is 15mg per day.[14]

Iron. Iron deficiencies are not uncommon in patients who have undergone both restrictive and malabsorptive procedures, although the more malabsorptive procedures carry a much higher risk.[5] The reported incidents in the literature are up to 47 percent.[19] Iron is the most abundant trace element in the body and is important in the replication of DNA and involved in the synthesis of the collagen triple helix.[24, 29] In addition, it is important in hemoglobin structure and oxygen transport.

The recommended daily allowance for iron for men and non-menstruating women is 10 and 15mg per day, respectively. Roux-en-Y gastric bypass patients with limited energy intake of 1,000 to 1,500 calories per day, normally only consume 6 to 9mg of iron from food ingested daily.[23] Patients can be supplemented with oral ferrous sulfate/gluconate. Many of the newer preparations also contain vitamin C to promote iron absorption and can be taken as single, daily doses of 100 to 200mg of elemental iron. Occasionally, patients who are refractory to oral iron supplementation require parenteral iron infusions.[30]

Calcium and Vitamin D. As stated previously, calcium and vitamin D are not necessarily required for proper wound healing, however, their metabolism is linked. Clinical significant deficiencies are seen most often following malabsorptive bariatric procedures and should be screened in perspective body contouring patients.[18, 23] Patients should receive 1,200 to 1,500mg of calcium citrate in 800 IU of vitamin D per day[31] to avoid deficiencies, which can lead to metabolic bone disease[32] and a long-term risk of osteoporosis and fractures. Screening for deficiencies include evaluation of ionized calcium, 25-hydroxyvitamin D, alkaline phosphatase, and parathyroid hormone levels,[33] as well as bone density studies when appropriate.

Smoking
In addition to micronutrient and macronutrient assessment and supplementation, smoking and other tobacco products cause micro vascular vasoconstriction by way of the action of nicotine and its activation of the sympathetic nervous system.[34] Cigarette smoke also contains carbonmonoxide, which contributes to tissue hypoxia by binding hemoglobin to form carboxyhemoglobin, which has a high affinity of oxygen and decreases the delivery of oxygen to peripheral tissues.[35, 36] Patients who smoke or have a history of heavy smoking are at increased risk for fat necrosis, wound infection, flap necrosis, and respiratory complications following surgery.[37, 38] Patients are advised to stop smoking at least four weeks prior to undergoing any body contouring surgery.[39, 40]

Summary
With the increased number of bariatric surgery procedures done in this country, body contouring surgery has reached a more diverse patient population requiring a variety of surgeries. Proper nutritional assessment and supplementation with a high biological protein and high-quality multivitamin, along with any specific nutrient deficiency, should be suffice in capturing the majority of nutrient deficiencies commonly experienced after bariatric surgery. It should be deemed a high priority to hopefully decrease morbidity and improve wound healing after body contouring surgery.

Part 3: A STAGED APPROACH TO GASTRIC BYPASS RECONSTRUCTION (GBRx™)

by MK Batra, MD, FACS; and RJ Nelson, BS, of Coastal Plastic Surgeons, Del Mar, CA

Background
As the percentage of Americans who are obese continues to increase, the demand for bariatric procedures is steadily following this trend.[41] Postoperatively, patients tend to lose massive amounts of weight leaving unwanted sagging skin around the torso and extremities, and have a need for body contouring surgical intervention. This section attempts to describe an approach to body reconstruction in the bariatric patient using a staged approach.

Using three separate stages to approach the body contouring concerns in the bariatric patient allows all surgeries to be completed within three six-hour blocks. This limits the amount of anesthesia, reduces the risk of DVT, and prevents problems with nerve compression injuries.[42] This approach also aids the patient in allowing the financial obligation to be spread out over a greater time period.

Discussion
Any patients who have undergone bariatric surgery or massive weight loss through medical regimens have found that the inelasticity of their skin and the large amounts of excess skin are equally as distressing as what led them to undergo bariatric surgery in the first place.[41] The face deflates, and the person may actually look more aged after massive weight loss. The arms have tremendous amounts of excess skin and it can be embarrassing to wear short-sleeve clothing. The breasts and chest wall sag and lose their volume. The abdominal wall is possibly the area that is affected the most, and skin can be found hanging over the pubic region and sometimes to the middle of the thighs.[43] The thighs themselves can be tremendously disfigured and have large volumes of excess skin, which can be both a functional and cosmetic problem. In the end, the whole body appears to need an overhaul in order to improve the cosmetic, functional, and psychological aspects associated with massive weight loss.

To help remedy these problems, our practice has devised the GBRx™ method for reconstructing the body. GBRx™ is a staged surgical approach to remove the unnecessary excess skin and provide a more contoured shape. The patients who undergo these procedures are usually at least 15 months out from their gastric bypass procedure and have plateaued with their weight loss. The “consult” usually starts in a support group-type setting with a question such as “Is there any way that exercising will tighten up the skin?” Ultimately the patient makes an appointment in the office to discuss his or her concerns in private and prioritize the approach; whether it be the abdomen, extremities, or face. The following is illustrative of the typical patient who undergoes GBRx™: During the first office consultation, the patient is given a form that addresses the basics of his or her journey so far. Their starting weight, their current weight, their goal weight, and their current BMI are all very important specifics.[44] Any ongoing comorbidities, medications, including oral contraceptives, and the priority list of areas they wish to address must also be addressed. Utilizing this information, I address the patient’s specific goals and their readiness for surgery. Detailed consideration is given to certain medical problems such as diabetes or poorly controlled hypertension. If these factors are present, I will coordinate the surgery with an internist on board for the preoperative and postoperative management. For the small number of patients on coumadin for atrial fibrillation or Plavix for heart stents, I work with their hematologist to wean the patient off of the blood thinners prior to proceeding. I have also elicited the help of the bariatric surgeon, pain control specialists, and psychiatrists prior to proceeding with surgery if the situation warrants. Finally, there is always a subjective component to my evaluation—if the patient seems unrealistic or noncompliant, I do not operate on them.

While there are certain commonalities between these patients, such as their desire to “look and feel better” about themselves, there is considerable difference between their expectations. Also, there has been shown to be an increased risk of postoperative complications with increasing BMI before body contouring surgery.[45] This increased risk, along with the patient’s expectations, has to be set and reinforced during the preoperative appointments. There are at least 2 to 3 preoperative visits before surgery. During these visits, I discuss patients’ goals and expectations with them. If both the physician and patient are not upfront about realistic goals and expectations, then both may face disappointment. I always discuss the potential for some relapse of their skin postoperatively. No matter how much tightening is done during surgery, at about 6 to 12 weeks there is some relaxation of the skin, whether it be in the arms, neck, or abdomen.[46] Therefore, at the consult I show pictures of patients that are 6 to 12 months out of surgery and the degree of relapse expected. The resulting scars are also shown. The timeline for recovery and potential complications are also discussed in the preoperative visits.[46] If both the patient and I feel that the goals are realistic, then consideration is given to move forward with surgery. GBRx™ is not considered unless the patient is at least one year from bariatric surgery and has three consecutive months of stabilized weight.[47, 45] Patients who have had laproscopic adjustable gastric bands (LAGB) typically take two years to be considered.

Preoperatively, the patient’s bloodwork is checked and an EKG is performed. Patients are also given information on how to prepare themselves nutritionally before surgery. We make sure they are taking their multivitamins and increase their protein intake to 1.5g/kg body weight two weeks before surgery and after surgery for at least six weeks postoperatively. The day prior to surgery, the patient is brought in for marking, which can take up to 30 to 45 minutes. This saves time the following day. The anesthesiologist typically calls the patient the evening before surgery and meets them in the preoperative waiting room.

On the day of surgery, the room is warmed prior to taking the patient back. In the operating room, the patient is placed on a warming blanket, compression stockings are applied, and any dentures and jewelry are removed. Any GBRx™ staged reconstruction procedure is expected to last less than six hours to reduce the complications associated with longer anesthesia times.[42] Heat loss, nerve compression injuries, blood loss, and blood clots in the lower extremities are the intraoperative complications which the surgeon and anesthesiologist work hard to avoid. Non-exposed areas are kept under a bair hugger (a device used to keep the patient warm), compression stockings are used and all bony prominences are kept adequately padded. In addition, the circulating nurse moves the extremities every 45 to 60 minutes. The blood loss is minimized by utilizing excellent surgical technique. In my patient population, only one patient has required a transfusion despite the global presence of anemia in this patient population, and there has been no incidence of DVT thus far in more than 270 patients. Generally, the reported incidence of DVTs in this patient population is about 2.9 percent.[48] After surgery the patient is transferred to an overnight stay for observation. I utilize an On-Q PainBuster® pain pump as well as pain medication, and the patient is given antibiotics during their overnight stay.[45 , 47, 48] Incentive Spirometry is used the night of surgery and continued for one week postoperatively. The morning after the surgery, the patient is ambulated with assistance and started on his or her bariatric diet. Current therapy does not include the use of enoxaparin (Lovenox), 1mg/kg unless there is evidence of a symptomatic DVT.[48] As of October 2006, no studies have looked at the safety of low-molecular-weight heparin in cutaneous surgery.[49]

The following morning, the patient is discharged and is expected to follow up with me at postoperative Day (POD) 3. (See Table 2 for all follow-up visits.) At the postoperative visit, the patient’s dressings are removed and additional compression garments are applied.

The patient is given permission to shower, but is instructed to keep the compression garments on at all other times. The patient is then seen at POD 7 to remove drains and to check wounds. The patient is seen again at two weeks postoperatively and any remaining drains are removed. For my thigh lift and facelift patients, lymphatic drainage by a certified massage therapist is instituted at this time and continues for 3 to 4 weeks. The patient then sees me on a weekly or bi-weekly basis for the next six weeks. After that, patients see me on a monthly basis for the next six months. Invariably, there is some relapse and I wait until at least six months to do any minor touch-ups.

While the surgical challenges and techniques in the massive weight loss patient continue to evolve, the GBRx™ staged reconstructions offer tremendous hope and benefit for patients who opt to undergo cosmetic and reconstructive procedures after massive weight loss.[50, 45] Our staged approach, as described below, allows for nearly all of the reconstructive procedures to be done in three stages. All of these stages can be completed within six hours, thereby limiting the amount of anesthesia, keeping the risk of DVTs to a minimum, preventing problems with nerve compression injuries, and allowing typically for just one overnight admission with less downtime.

GBRx™ Stage 1
Stage 1 typically involves addressing the abdominal and chest wall regions. Almost invariably, the loose skin and abdominal wall weakness with bulging are the primary concerns for the patient. An extended abdominoplasty is planned. The surgical incisions are designed such that there is an elevation of the pubic region as well as the medial thighs and the portions of the lateral thigh. In female patients, the breasts are most often done at the same time, whereas in male patients’ chest wall contouring can be done. On occasion, stage 1 in both male and female patients can be combined with an arm lift.

As always, a preoperative evaluation of each individual patient will help determine the safest and most beneficial options for any given patient. I opt to do the “front” of the body, including the abdominal wall, breasts, and chest as one stage rather than doing a complete body lift. The main reason for this approach is that a complete body lift does not allow for as extensive a tightening as staging the front and back separately. With the complete body lift, it is very difficult to flex the patient on the surgical table at 45 degrees without causing significant stress on their back wound.[47] The reason for flexing the patient at 45 degrees on the surgical table is to remove as much of the skin as possible from the anterior abdominal wall. The excess skin of the abdominal wall is removed and several layers of muscle tightening are done in order to flatten the abdominal wall. In addition, any hernias that may be present in the abdominal wall are addressed at this time. Finally, I will incorporate liposuction in areas that require further deflation. On the whole, liposuction has not been a very rewarding technique in the post-bariatric surgery patient.

The breasts most likely require both a lift and augmentation. I prefer to use silicone implants in my practice, as I feel they give a much more natural feel and shape to the breast. Usually the implants are placed under the muscle and the lift and augmentation are done at the same time. As mentioned earlier, depending on the complexity of the case, I will often do an arm lift at the same stage. Drains are placed in the arms and the abdominal wall. I do not use drains in the breasts. In addition, a pain pump catheter is placed along the muscle plication of the abdominal wall to control postoperative pain. An abdominal binder is worn as well as a surgical bra, and the patient spends one night in the recovery facility and is discharged the following morning. Typically, within one week, the arm drains are removed. Typically, in 7 to 10 days, the abdominal drains are removed. An abdominal binder is required for 3 to 4 weeks and massage of the breasts is implemented as early as one week. It usually requires 6 to 8 weeks between stages if a second stage is planned.

GBRx™ Stage 2
The second stage addresses the laxity of the upper and lower back, the buttocks, and the medial thighs. I address the upper folds of the back through an incision that is made along the side of the chest pulling the upper back skin forward and excising it. This results in a scar on the side of the chest, which is camouflaged with the arms down. The lower back folds are addressed as part of the back and buttock lift. Both of these areas are addressed with the patient placed face down on the surgical table. The upper back and lower back generally takes 2 to 3 hours. Afterwards, the patient is then turned onto his or her back and the medial thighs are addressed.

The thighs are typically done through a vertical incision that starts in the groin crease and can extend all the way down to the knees. This appears to be the most effective way to get rid of all the excess skin and still leave a scar in an area, which is not obvious. Drains are placed along the chest wall, the lower back, and medial thighs. Once again, the stage is completed within a six-hour time frame, and the patient is sent to an overnight recovery facility. The following morning, the patient is assisted in getting out of bed and walking and is typically discharged to home. The thighs are perhaps the most difficult recovery for patients in that there is a higher incidence of forming seromas lymphoceles (small pockets of fluid) and prolonged swelling.[45, 47, 48] I often implement lymphatic drainage postoperative in order to allow the swelling to dissipate faster.

GBRx™ Stage 3
The third, and usually the final stage, addresses the aging and deflation of the face. At this stage, a facelift, neck lift, brow lift and upper and lower blepharoplasty is planned. This procedure typically takes 5.5 to 6 hours and perhaps has the most dramatic impact on the patients’ sense of wellbeing and their overall psychological outcome. Once again, an overnight stay is required not so much for pain control, but to monitor for any bleeding from the facelift procedure overnight. Contrary to popular belief, facelifts are not very painful procedures and this is perhaps the easiest recovery for the patient.[46] While the majority of patients undergo GBRx™ stage 1, about 50 percent will go on to inquire about the next stage and this can be undertaken as early as six weeks depending on their recovery. Only about 20 percent of the patients in our practice will go on to have all three stages. This may be a reflection of the financial implications as well as their self-image. Insurance unfortunately does not see these as reconstructive procedures rather as cosmetic procedures. We, however, always submit the procedures for insurance coverage along with photographs. The only procedures covered on a regular basis are the panniculectomies. The patient then pays for any additional work that may be done at the same time. In descending order, the most common areas to be addressed are abdomen, breast and chest, arms, thighs, back and buttocks, and face and neck.

The GBRx™ staged approach limits not only the amount of recovery in the hospital for the patient, but also the financial obligations due to multiple procedures being performed at each individual stage. Foremost, a surgical team invested in body contouring for the massive weight loss patient is a prerequisite in order to get these multiple procedures completed in a six-hour time frame in a predictable fashion. In our practice, typically two surgeons or a surgeon and our physician assistant is involved at both stage one and stage two, while only one surgeon is required at stage three. Further, as any surgeon whose practice primarily takes care of reconstructive surgery for massive weight loss patients will tell you, there is always a degree of relapse of the skin with any of these procedures. There have been several patients who required further tightening of the arms at the second stage or the abdominal wall at the second stage.

Complications and conclusions
Our practice has employed these reconstructive options in more than 200 patients at this time without a single incidence of deep venous thrombosis, and only one patient requiring blood transfusion after a GBRx™ surgery.

There has been approximately a 10-percent incident of seroma of the abdomen, and 13-percent incident of seromas of the thighs. Overall, our patients’ satisfaction rate has been extremely high and more than 87 percent of our patients have reported that they have been either very satisfied or extremely satisfied with their outcomes. These patients comprise the most satisfied and realistic patients in my practice. They also tend to be a very tight-knit and thoroughly researched group of patients. They are for the most part extremely grateful as evidenced by their loyalty to the practice and their referral of other members of the support group.

REFERENCES
1.        ASPS website; www.asps.org. Accessed February, 2008.
2.        Mitchell J. The desire for body contouring surgery after bariatric surgery. Obes Surg. 2008;10:1308–1312.
3.        Buckley M. Body Contouring after Massive Weight Loss. In: Buchwald H. Surgical Management of Obesity. Saunders Elsevier: 2007.
4.      Sawer DB. Psychological considerations of bariatric surgery. Plast Reconstr Surg. 2008:121(6);423–434.
5.      Agha-Mohammadi MB, Chir B, Hurwitz DJ. Nutritional deficiency of post-bariatric surgery body contouring patients: what every plastic surgeon should know. Plast Reconstr Surg. 2008;122(2):604–613.
6.      Faintuch J, Matsuda M, Cruz, ME. Severe protein-calorie malnutrition after bariatric procedures. Obes Surg. 2004;14(2)175–181.
7.      Moize V, Geliebter A, Gluck ME, et al. Obese patients have inadequate protein intake related to protein intolerance up to 1 year following Roux-en-Y gastric bypass. Obes Surg. 2003;13(1):23–28.
8.      Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999;9(2):150–154.
9.      Avinoah E, Ovnat A, Charuzi I. Nutritional status seven years after Roux-en-Y gastric bypass surgery. Surgery. 1992;111(2):137-142.
10.      Shils ME, Olson JA, Shike M. Modern Nutrition in Health and Disease, 8th Ed. Philadelphia: Lea & Febiger, 1994.
11.      Holick M. Vitamin D deficiency. NEJM. 2007;357:266–281.
12.      Thomas D. Improving outcome of pressure ulcers with nutritional interventions: a review of the evidence. Nutrition. 2001;17(2):121–125.
13.      Freiman M, Seifter E, Connerton C, et al. Vitamin A deficiency and surgical stress. Surgery Forum. 1970;21:81–82.
14.      Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg. 2006;117 (7 Suppl):42S–58S.
15.      Clements RH, Katasani VG, Palepu R, et al. Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. Am Surg. 2006;72(12);1196–1204.
16.      Janssen de Limpens AMP. The local treatment of hypertrophic scars and keloids with topical retinoic acid. Br J Dermatol. 1980;103(3):319–323.
17.      Skroubis G, Sakellaropoulos, G., Pouggouras, K, et al. Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg. 2002;12(4):551–558.
18.      Sebastian J. Bariatric surgery and work-up of the massive weight loss patient. Clin Plast Surg. 2008;35(1):11–26.
19.      Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin B12 and folate deficiency clinically important after Roux-en-Y gastric bypass? J Gastrointest Surg. 1998;2(5):436-442.
20.      Mason M, Jalagani H, Vinik AL. Metabolic complications of bariatric surgery: diagnosis and management issues. Gastroenterol Clin North Am. 2005;34(1):25–33.
21.      Tanaka H, Okada T, Konishi H, et al. The effect of reactive oxygen species on the biosynthesis of collagen and glycomsaminoglycans in cultured human dermal fibroblasts. Arch Dermatol Res. 1993;285(6):352–355.
22.      Ehrlich H, Tarver H, Hunt TK. Inhibitory effects of vitamin E on collagen synthesis and wound repair. Ann Surg. 1972;175(2):235–240.
23.      Slater GH, Ren, CJ, Siegel N, et al. Serum fat soluble vitamin deficiency and abnormal calcium metabloism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8(1):48–55.
24.      Myers W, Leong, M., Phillips, LG. Optimizing the patient for surgical treatment of the wound. Clin Plast Surg. 2007;34:607–620.
25.      Kloth L, McCulloch, JM. Wound healing: alternatives in management. 3rd edition. Philadelphia: FA Davis Company; 2002.
26.      Demling R, DeBiasse, MA. Micronutrients in critical illness. Crit Care Clin. 1995;11(3):651–673.
27.      Lansdown A, Mirastschijski U, Stubbs N, et al. Zinc in wound healing: theoretical, experimental, and clinical aspects. Wound Repair Regen. 2007;15(1):2–16.
28.      Prasad A, Miale A Jr, Farid Z, et al. Zinc metabolism in patients with the snydrome of iron deficiency anemia, hepatosplenomegaly, dwarfism, and hypogonadism. J Lab Clin Med. 1963;61:537–549.
29.      Burns J, Mancoll JS, Phillips LG. Impairments to wound healing. Clin Plast Surg. 2003;30(1):47–56.
30.      Neve HJ, Bhatti WA, Soulsby C, et al. Reversal of hair loss following vertical gastroplasty when treated with zinc sulphate. Obes Surg. 1996;6(1):63–65.
31.      Kushner R. Managing the obese patient after bariatric surgery: a case report of severe malnutrition and review of the literature. J Parenter Enteral Nutr. 2002;24(2):126–132.
32.      Parfitt A, Miller MJ, Frame B, et al. Metabolic bone disease after intestinal bypass for treatment of obesity. Ann Intern Med. 1978;89(2):193–199.
33.      Goldner W, O’Dorisio TM, Dillon JS, et al. Severe metabolic bone disease as long-term complication of obesity surgery. Obes Surg. 2002;12(5):65–92.
34.      Benowitz N. Clinical pharmacology of nicotine. Annu Rev Med. 1986;37:21–32.
35.      Heliovaara M, Karvonen, MJ., Vilhunen, R., et al. Smoking, carbon monoxide, and atherosclerotic diseases. Br Med J. 1978;6108:268–270.
36.      Astrup P, Kjeldsen K. Carbon monoxide, smoking, and atherosclerosis. Med Clin North Am. 1974;58(2):323–350.
37.      Selber J, Kurichi JE, Vega SJ, et al. Risk factors and complications in free TRAM flap breast reconstruction. Ann Plast Surg. 2006;56(5):492–497.
38.      Livingston E, Arterburn D, Schifftner TL, et al. National Surgical Quality Improvement Program analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse outcomes. J Am Coll Surg. 2006:203(5):625–633.
39.      Forrest C, Pang CV, Lindsay WK. Pathogenesis of ischemic necrosis in random-pattern skin flaps induced by long-term low-dose nicotine treatment in the rat. Plast Reconstr Surg. 1991;87(3):518–528.
40.      Chang D, Reece GP,  Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000;105(7):2374–2380.
41.   Gastric bypass surgery popularity leads to jump in plastic surgery procedures. Press Release: American Society of Plastic Surgeons, 2003.
42.      McAlister FA, Bertsch K, Man J, et al. Incidence of and risk factors for pulmonary complications after nonthoracic surgery. Am J Respir Crit Care. 2005:171:514.
43.      Song AY, Jean RD, Hurwitz DJ, et al. A Classification of Contour Deformities after Bariatric Weight Loss: The Pittsburgh Rating Scale. Plast Reconstr Surg. 2005:116(5):1535–1544.
44.      Gusenoff JA, Pennino RP, Messing S, et al. Post-Baratric Surgery Reconstruction: Patient Myths, Perceptions, Cost and Attainability Strategies. Plast Reconstr Surg. 2008:122(1);1–9.
45.      Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the massive weight loss patient. Plast Reconstr Surg. 2006;117(2):414–430.
46.      Swanson L. Welcome to your facelift: What to expect before, during, and after cosmetic surgery. Plast Reconstr Surg. 1998;102(1):260.
47.      Strauch B, Herman C, Rohde C, Baum T. Mid-Body contouring in the post-bariatric surgery patient. Plast Reconstr Surg. 2006;117(7):2200–2211.
48.      Shermak MA, Chang DC, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg. 2007;119(5):1590–1596.
49.      Khalifeh MR, Redett RJ. The management of patients on anticoagulants prior to cutaneous surgery: case report of a thromboembolic complication, review of the literature, and evidence-based recommendations. Plast Reconstr Surg. 2006:118(5);110e–117e.
50.      Matarasso A, Roslin MS, Kurian M. Bariatric surgery: an overview of obesity surgery. Plast Reconstr Surg. 2007:119(4):1357–1362.

Category: Past Articles, Practice Management Perspective

Comments are closed.