Introduction to Body Contouring after Bariatric Surgery

| March 7, 2008

by Constance M. Chen, MD, MPH; Lidie Lajoie,
BA; Robert T. Grant, MD; and Jason A. Spector,
MD
From the Division of Plastic Surgery,
New York-Presbyterian Hospital, New York, New York

INTRODUCTION
Morbid obesity (BMI>40) afflicts over eight million people in the United States
alone.1, 2 Although diet and exercise may be the first line of treatment, the severely
obese patient has often reached a tipping point in which his or her immense size limits
mobility and the potential for exercise. For these patients, the most effective weight
loss therapy is bariatric surgery. Improved techniques, better patient safety, and
excellent outcomes have encouraged more obese patients to undergo surgery, with the
majority of bariatric patients now losing more than 50 percent of their excess weight.
This massive weight loss inevitably leaves patients with a “deflated” appearance, in
which large amounts of stretched-out skin hang from the arms, breasts, abdomen,
flank, mons, back, buttocks, and/or thighs.3 Not only is the redundant skin unsightly,
but patients often complain of difficulty with hygiene and mobility. To address these
issues, the plastic surgeon is often called upon to solve the problem with post-bariatric
surgery body contouring.2 The scope of this article is an introductory illustration of
body contouring.
REFINEMENT OF TECHNIQUES/IMPROVING OUTCOMES
The torso and abdomen areas are
usually the first focus of patients who
present for post-bariatric surgery
body contouring. The procedure that
is chosen depends upon the amount
and distribution of excess skin and
fat. When the redundant skin is
limited to the anterior abdomen, the
patient is a candidate for a standard
abdominoplasty. The skin and fat
below the belly button is removed,
with a horizontal scar hidden in the
bikini line. The underlying muscle
layer is also plicated to recreate a
tighter waist. When there is so much
excess skin and fat that recurrent
infections become a problem, a simple
excision of the overhanging pannus or
apron of excess skin and adipose
tissue can be curative. A
panniculectomy may also be the only
body contouring procedure covered
by third party payers (Figures 1A-D.). When there is a significant
amount of extra skin in both the front
and back of the body, as is the case
for most post-bariatric patients, a
circumferential abdominoplasty or
lower body lift is required. This
procedure will address contour
deformities of the abdomen, sides,
and back, and can concurrently
tighten and lift the buttocks, mons
pubis, and lateral thighs.4
Finally, those patients who have
tremendous amounts of excess skin
may need tissue resection in both the
horizontal and the vertical planes.
This requires a fleur-de-lis pattern of
excision that leaves both horizontal
and vertical scars. Patients who had
previous open bariatric surgery will
already have a vertical midline scar.

For patients who have had
laparoscopic surgery, the additional
scar is usually a worthwhile tradeoff
for a significant reduction in
transverse skin excess.
After the abdomen, the second
area of concern is usually the chest
and breasts. For both men and
women, the major breast deformity
after massive weight loss is ptosis, or
sagging. Correction of the postbariatric
deformity in both sexes
requires moving the nipple-areola
complex superiorly to its proper
anatomic position. In female patients,
the empty “pancake” breast must be
filled and natural projection
recreated, which often requires an
implant in combination with a breast
lifting skin excision or mastopexy
(Figures 2AB, 3AB.). Surgeons may
also recruit excess fat and tissue from
the patient’s upper lateral chest or
back to augment the breast volume.
In some instances (in both men and
women), the nipple-areola complex
has sagged so far from its origin that
it must be detached and replaced as a
graft. When a free nipple graft is
performed, the patient can expect the
grafted nipple to be numb and
discolored.6

Although some techniques for a
chest lift in the male post-bariatric
patient have been developed that
leave a scar hidden in mid-axillary
line to avoid noticeable scars on
anterior chest,5 in many cases in
which there is significant ptosis,
visible incisions on the anterior are
unavoidable.
Finally, the extremities are also
areas of significant dissatisfaction in
patients who have undergone massive
weight loss. Hanging skin from the
arms may give the appearance of “bat
wings” (Figures 2AB, 3AB.), while
drooping skin from the thighs may
make patients too embarrassed to
wear shorts and bathing suits. For
patients who only have a small
amount of excess tissue, small
incisions can be hidden in the armpit
for an arm lift or in the groin for a
thigh lift. The post-bariatric
deformities, however, can rarely be
treated by these “minimal” incisions.
For larger deformities, a longitudinal
incision along the arm or the leg is
necessary to perform an adequate
skin excision. An extended arm lift
can also address lateral chest laxity
and be performed with a breast lift or
reduction in order to further improve
contour.7 In all areas of the body,
adjuvant liposuction can be used to
tailor remaining contour deformities.
PREVENTION OF BLOOD LOSS AND
BLOOD CLOTTING DURING
SURGERY
Prior to undergoing body
contouring, all patients need standard
preoperative labs as well as an
assessment of their nutritional status.
As a result of gastric bypass, about
half of all patients who have
undergone massive weight loss are
anemic.8 A complete blood count will
detect underlying anemia and guide
the physician toward delaying surgery
for treatment if necessary. The
importance of blood loss in postbariatric
body contouring cannot be
underestimated. Not surprisingly,
combining three or more procedures
in one operation is also associated
with an increased risk of blood
transfusion.9 Once the decision has
been made to proceed with surgery,
however, tumescent solution (which
contains a small amount of the
powerful vasoconstrictor epinephrine)
can be used to decrease
intraoperative blood loss.10 Careful
hemostasis is also obtained in the
standard fashion with electrocautery,
surgical clips, and vessel ligation.

On the other end of the spectrum,
venous thromboembolism is also a
significant concern in post-bariatric
body contouring. A history of obesity,
combined with a lengthy body
contouring procedure, automatically
places patients at moderate to high
risk of forming blood clots, regardless
of any other underlying medical
problems. For example, one published
report revealed a 1.1-percent
incidence of deep vein thrombosis
and a 0.8-percent incidence of
pulmonary embolism in
abdominoplasty patients.11
Thus, depending on the
procedure and the patient’s
risk stratification, a variety
of mechanical and
pharmacological methods of
prophylaxis should be used.

All patients should be
positioned with a pillow
under the knees to allow for
five degrees of flexion and
maximum blood flow
through the popliteal veins.12
Elastic compression
stockings can be used to
reduce the risk of venous
thrombosis.13 Intermittent
pneumatic compression
stockings should be
instituted before the
induction of anesthesia and
continued intraoperatively
and postoperatively until the
patient is ambulatory.12, 14
Early ambulation is advised
for all patients.

Postoperative heparin or
low-molecular-weight
heparin can also be used as
an anticoagulant, although
all blood thinners must be
weighed against the risk of
bleeding.12,14
ABDOMINAL HERNIAS AND NUMBNESS
Abdominal wall hernias
affect approximately five
million Americans, and in
2003 alone 360,000 ventral
hernia repairs were
performed.15 Hernias are
believed to be related to
anatomic abnormalities that
are susceptible to increased
intra-abdominal pressure
exceeding abdominal wall
counterpressure.15 Not
surprisingly, the incidence of
incisional hernia after open
gastric bypass has been
found to increase with
increasing body mass index
(BMI), and has been
reported as high as 20
percent in some series.16 A
recent meta-analysis
revealed an 8.6-percent
incidence of incisional hernia
after open gastric bypass
procedures compared to a
0.5-percent incidence after
laparoscopic gastric bypass
techniques.17 Although a thorough
preoperative physical examination will
often detect ventral hernias, the
plastic surgeon must be vigilant to
recognize and repair hernias found
intraoperatively. Failure to do so can
result in the unsuspecting surgeon
entering the bowel while performing a
body contouring procedure, causing
significant morbidity. While the trend
toward laparoscopic bariatric
procedures has reduced the incidence
of incisional hernias, the plastic
surgeon must be aware of the need to
repair both primary and incisional
hernias during procedures around the
abdomen.10
ABDOMINOPLASTY AND SENSATION
The anterior branches of the lower
intercostal nerves run between the
abdominal muscles, penetrating
through the muscle where perforating
anterior cutaneous nerves supply
sensation to the skin of the abdomen
in a stepwise fashion. During
abdominoplasty, these perforating
nerves are necessarily severed as the
anterior abdominal skin and
subcutaneous fat is raised from the
underlying fascial plane. A recent
study of abdominal wall cutaneous
sensitivity confirmed anecdotal
reports that sensibility is decreased
after abdominoplasty, particularly in
the torso and suprapubic region.18 The
loss of sensation is usually transient,
with pain, temperature, and pressure
sensation returning after an average
of 6 to 7 months.19
PREVENTION OF COMPLICATIONS
Complications of body contouring
include wound dehiscence, seroma,
hematoma, lymphocele (collection of
lymph), infection, and bleeding
requiring reoperation or transfusion.

More rare but still feared
complications include
thromboembolism and even death.
Prophylactic antibiotics and sterile
technique limit the risk of infection.
Prior to surgery, patients should be as
close as possible to their goal weight,
as many studies correlate a higher
BMI at the time of surgery with a
higher rate of complications.4,8,10

Smoking cessation is essential for all
patients, as nicotine use constricts
blood vessels, encourages blood
clotting, and impairs wound healing.
Wounds can also fall apart early in the
postoperative course as a result of
excessive pulling on the edges by the
patient or caregiver.

In order to decrease the
accumulation of fluids in the wound
or seroma, drains are usually used.
The surgeon may also use three-point
suturing of superficial to deep fascia
to obliterate dead space or preserve a
thin layer of fat in the deep fascia to
maintain lymphatic drainage.8

Innovations like fibrin tissue sealants
may also be used to assist with tissue
adherence and have also been shown
to decrease the size and frequency of
fluid collections.20 In abdominal
contouring procedures, conservative
undermining in the upper torso
decreases risk of wound healing
problems.9

Likewise, brachioplasty
complications include seroma,
hypertrophic scarring, wound
infection, wound dehiscence, suture
abscess, and lymphocele.22 Injury to
the medial antebrachial cutaneous
nerve can cause numbness, but the
risk may be minimized by preserving a
cuff of at least 1cm of fat on the deep
fascia during dissection.22 As is the
case for other body areas,
undermining should be minimized to
decrease the incidence of seromas
and edema.7 Seromas can also be
reduced via conservative skin
resection, use of drains, and
postoperative compressive dressings.
Axillary scar contractures can be a
late complication, but may be
prevented by using a T- or L-shaped
axillary resection pattern or a Z-plasty
incision when crossing the axilla.7
CONCLUSION
Post-bariatric surgery body
contouring is an important adjunct
after massive weight loss. The last
several years have seen a significant
refinement of techniques with
improved outcomes. The
incidence of wound
infections, abdominal
hernias, and numbness has
improved as surgeons
devise ways to avoid
problems before, during,
and after surgery. As
bariatric surgery grows in
popularity, post-bariatric
body contouring is
keeping pace as the
fastest-growing
subspecialty within plastic
surgery. Despite its many
challenges, body
contouring usually
provides a high degree of
patient and surgeon
satisfaction as it completes
the patient’s transition
into a “formerly obese”
person.
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Surgical solutions to the problem
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Category: Body Contouring Perspective

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