by Amy S. Colwell, MD
From the Division of Plastic Surgery, Mass General Hospital, Boston Massachusetts
There has been a dramatic rise in the number of bariatric procedures performed in the US, and this has inspired a new growth field in plastic surgery: post-bariatric body contouring. While bariatric surgery successfully induces long-term weight loss and improves or cures such ailments as diabetes and osteoarthritis, it does not reduce the patient’s excess skin.
Instead, loose rolls of skin drape around the patient’s frame and detract from the overall success of the bariatric procedure (Figure 1). The goal of post-bariatric body contouring is to maximize the results of weight loss surgery by removing the excess skin and reshaping the body into its normal proportions.
This review will discuss advances that have been made in patient selection, technique, and safety to optimize results in this unique population.
After surgically induced massive weight loss, the patient often inquires about removal of the sagging skin that remains despite the fatty tissue loss. Although the patient may look good in clothing, he or she embarrassed to take off his or her clothes to reveal this disfigurement. Before embarking on surgical correction of these deformities, several criteria must be met to enhance the outcome for the patient.
Stable weight. A plateau in weight loss is achieved following bariatric surgery, and this is an ideal time to consider body contouring. Premature surgery prior to this point is not advisable as further weight loss will detract from the patient’s overall result with recurrent skin laxity. It is sometimes difficult to discourage the patient from having contouring procedures before his or her plateau as the skin deformity can be significant. However, a gentle reminder that the outcome would be enhanced after weight loss is complete and that insurance is unlikely to pay for revisions is often enough to encourage the patients to wait.
Body mass index (BMI). It is well recognized that patients plateau at different BMIs and that further weight loss may not be recommended after this level has been achieved. For technical and safety reasons, plastic surgeons often prefer that the patient’s BMI is 32 or less to be considered for contouring regardless of the starting BMI. This recommendation does not apply to patients considering panniculectomy only, which is defined as removal of skin and fat of the abdomen without undermining of abdominal flaps or plication of the rectus muscles. Panniculectomy can be performed in anyone able to withstand general anesthesia as no undermining is done and the surgical time is relatively short. Rather, the recommendation applies to more advanced surgical techniques of abdominoplasty and lower body lift. Patients with a BMI between 32 and 35 are considered for contouring procedures on an individual basis, but those with a BMI greater than 35 are limited to panniculectomy as there is a dramatic increase in complications in this population.
Nutrition. Protein is an essential building block for wound healing, and deficiencies result in an increased risk of wound break-down. A simple, cheap way to assess for protein adequacy is by taking a dietary history of protein intake. If a deficiency is suspected, serum albumin, pre-albumin, and transferrin may be measured. A history is also taken to assess for vitamin and mineral deficiencies known to occur following bariatric surgery and patient compliance with supplements. Routine levels of vitamin A, vitamin C, and zinc are typically not measured; however, as essential components of wound healing, their deficiencies could contribute to wound healing problems.
American Society of Anesthesiologists (ASA) classification. The ASA classification is a scheme anesthesiologists use as an imprecise guide to a patient’s overall health and a predictor for surgical and anesthetic risk. Patients who are to undergo lengthy contouring procedures should be an ASA class I or II.
Nicotine cessation. Among contraindications to contouring procedures, active smoking tops the list. Smoking leads to increased skin necrosis and wound breakdown following abdominoplasty, and it is a significant risk factor for any contouring procedure.
Many terms are used to describe techniques utilized by plastic surgeons to remove skin excess in different areas of the body, and a brief description of some of the more commonly used terms is prudent. Several of the following techniques have been designed specifically for post-bariatric patients to address their unique anatomy.
Panniculectomy. This technique describes excision of a wedge of skin and fat in the abdomen with no undermining, plication, or liposuction. This procedure is often covered by insurance companies to improve function and quality of life in post-bariatric patients by alleviating rashes, improving ability to exercise, decreasing back pain, and improving sexual function.
Abdominoplasty. Like panniculectomy, an abdominoplasty removes excess skin and fat of the abdomen. In addition, wide undermining is undertaken in order to maximize the amount of skin removed and the rectus muscles are plicated in the midline to narrow the waist. It is sometimes combined with flank or hip liposuction to improve results. Caution should be exercised when combining abdominoplasty with liposuction as this can potentially threaten the blood supply if performed improperly and lead to skin necrosis.
Lower body lift/belt lipectomy. A lower body lift is particularly suited for the massive weight loss patient whose skin excess involves the anterior abdomen, lateral thighs, and posterior buttocks. The anterior incision is continued posteriorly so that a circumferential wedge of skin and fat is removed. Belt lipectomy is another term for this technique and differs only in scar placement. In patients who have lost excessive fat in their buttock region from the bariatric surgery, some skin and fat that would otherwise have been discarded is retained and shifted into the buttock region as “gluteal auto-augmentation” flaps based on the superior gluteal artery.
Breast reduction/reduction mammaplasty. In obese patients prior to massive weight loss, the breasts are often protuberant and heavy. Breast reduction can alleviate some of the discomfort and pain experienced by these women and the procedure is routinely covered by insurance. With massive weight loss, the volume of the breasts often dramatically decreases, so it is uncommon for a woman to have enough excess breast tissue to qualify for breast reduction.
Mastopexy (breast lift). The most common breast procedure for post-bariatric patients is a breast lift, or mastopexy. In this technique, the breast is reshaped and the nipple placed more centrally on the breast mound. If extra volume in the breast is desired, skin and fat from the axillary roll and mid-back region can be transferred to the breast as a flap based on the intercostal artery perforators (Spiral or ICAP flap—Figure 2).[7, 8] This technique has the added advantage of removal of the undesirable excess tissue under the arm.
Gynecomastia correction. Male gynecomastia following weight loss is commonly characterized by inelastic, droopy skin of the chest with localized fatty deposits. Men are reluctant to take their shirts off and expose the deformity. Traditional gynecomastia correction with liposuction and a periareolar incision is typically not enough to correct the large amount of extra skin on the chest. Instead, correction involves a combination of liposuction and surgical excision, leaving a horizontal scar along the inferior border of the chest or extending medial and lateral from the nipple in a “boomerang” configuration.
Brachioplasty (arm lift). The upper arm deformity is a common cause of concern and dissatisfaction in post-bariatric patients. The excess skin and fat in this region is readily exposed with tank tops or short sleeve shirts in warmer weather. Brachioplasty techniques remove this excess skin and fat in the upper arm and chest wall. Unfortunately, our ability to correct the contour deformity comes at the cost of a scar running on the inner surface of the upper arm (Figure 3). For most patients, the tradeoff is worthwhile and the scar is hidden with the arms placed at the side.
Vertical thigh lift. The thigh deformity consists of excess tissue extending from the groin to the knee. The original crescent thigh lift technique is not sufficient to correct the massive weight loss deformity. Like the brachioplasty technique, contour correction of the vertical thigh comes at the expense of a scar running along the inner medial thigh.
In contrast to the typical healthy patient seeking elective plastic surgery, post-bariatric body contouring patients are more complex and have more reported complications. It is therefore prudent as a specialty that an effort be made to optimize safety in this population, and specific articles have been written to review best safety practices and are summarized as follows. Intraoperative hypothermia is a concern with long procedures and exposure of large surface areas. Therefore, pre-warming with forced air heating blankets and warming the tumescent and intravenous fluid may help avoid drops in central core temperature. Particular attention is also paid to padding pressure points and changes from supine to prone position to avoid inadvertent iatrogenic injuries. A reverse Trendelenburg slant can help avoid the increase in intraocular pressure sometimes observed with prolonged prone positioning. The incidence of thromboembolic events is dramatically increased with body contouring procedures and no consensus currently exists on prophylactic thromboembolism prevention. Most surgeons agree that mechanical prevention with pneumatic compression devices should be initiated for all patients and chemoprophylaxis should be strongly considered for these patients. Routine practices for preoperative antibiotics and prevention of seroma with drains or quilting sutures are also followed.
One final question that often arises is the feasibility of performing more that one procedure in one operative setting. This can be advantageous for the patient in planning for time off work, arranging for postoperative help, and saving money. This question is typically answered on a case-by-case basis according to the patient’s anatomy and current weight as well as the length of time he or she is able to take off work. The answers may also vary from surgeon to surgeon depending upon the amount of assistance in the operating room and the surgeon’s comfort level with the procedures. Since blood loss can be significant when multiple procedures are combined, I typically ask my patients to auto-donate two units of blood 2 to 4 weeks before surgery if they are having three or more procedures in the same operative setting. The blood is given back to the patient in the latter half of the operation. In my experience, this dramatically enhances the patient’s recovery. Together, the patient and surgeon can work together to devise a plan that makes sense for both and is safe.
Post-bariatric body contouring is a new, exciting specialty in plastic surgery that can maximize the results obtained from weight loss surgery. It is increasingly recognized as an important component for total care of the post-bariatric patient, and the plastic surgeon may soon become part of the standard multidisciplinary team that currently cares for these patients.
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Category: Body Contouring Perspective