Nutritional Management Related to Plastic Surgery Among Bariatric Patients: A Meta-analysis

by Silvia Leite Faria, MSc, RD; Orlando Pereira Faria, MD; Mariane de Almeida Cardeal; and Heloisa Rodrigues de Gouvêa

Bariatric Times. 2012;9(8):14–19

AUTHOR AFFILIATION: Silvia Leite Faria, MSc, RD; Mariane de Almeida Cardeal; and Heloisa Rodrigues de Gouvêa are nutritionists at Gastrocirurgia de Brasília, Brasília, Brazil. Orlando Pereira Faria, MD, is also from Gastrocirurgia de Brasília.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

ABSTRACT
A bariatric patient may require plastic surgery interventions to treat excess skin after their rapid weight loss. This meta-analysis aims to collate the current knowledge regarding guidelines for the the optimization of the nutritional status in this patient population.

Research was conducted by specialists in bariatric surgery from the Clinic Gastrocirurgia de Brasília, Brazil. The authors searched the PubMed database between 2000 and 2011 using the following keywords: bariatric surgery, plastic surgery, wound healing, weight loss, nutritional deficiencies, protein deficiency, vitamin C, and iron. Forty-eight articles, two websites of professional organizations, and three book chapters were included. The authors concluded that in addition to routine supplementation, bariatric patients should take nutritional supplements to prevent complications, including protein, essential fatty acids, zinc, iron, vitamin C, and vitamin A, and that nutritional supplementation is often necessary to improve the immune system, prevent skin infections and improve healing after plastic surgery.

Introduction
Bariatric surgery is undoubtedly the best treatment currently available for morbid obesity and its associated comorbidities.[1] The number of these surgical procedures is increasing worldwide, reaching a total of 344,221 in 2008, with the Roux-en-Y gastric bypass (RYGB) most commonly performed.[2] The criteria for success after bariatric surgery include the loss of more than 50 percent of the preoperative excess weight, followed by weight maintenance over a long-term follow-up period.[3]

Following excessive post-surgery weight loss, patients may incur certain cutaneous anomalies, such as excess skin, skin flaccidity, pain, fungal infections, dermatitis, and rashes.[4,5] Consequently, the patient may also develop physical problems, including poor posture and mobility, difficulty in wearing appropriate clothing, or difficulty in maintaining personal hygiene.[6–9] Psychological fragility and low self-esteem may also occur, despite the increase in self-esteem after considerable weight loss results from bariatric surgery.[6–9] This situation can be improved with plastic surgery.[6–9]

The aim of undergoing plastic surgery after bariatric surgery is to maximize the bariatric surgery. Plastic surgery can remove excess skin and contour the patient’s body more proportionately.[9,10] These results can contribute to an improved quality of life for patients, a higher level of self-esteem, and a growing satisfaction with their body image.[11]

It has been estimated that after undergoing bariatric surgery, more than 65 percent of patients wish to undergo plastic surgery, the majority of whom are women.[9] In practice, the number of patients who actually undergo plastic surgery varies between bariatric surgery centers, reaching 47 percent of patients in one study.12 The lower percentage in other services is possibly due to the absence of government funding for this surgery, fear of further surgery, or a lack of patient information.[9] The number of plastic surgeries performed after massive weight loss is increasing, with 52,000 post-bariatric plastic surgery procedures performed in 2003 and almost 53,000 recorded in 2010 among members of the American Society of Plastic Surgeons alone.[13,14]

It is important for caregivers of this patient population to note that individual attention will be needed, as each post-bariatric patient will present different body contouring requirements as a result of weight loss.[15] The most frequently performed procedures after bariatric surgery are abdominoplasty, lipectomy, circumferential abdominoplasty (lower body lift/belt lipectomy), mastopexy (breast lift), breast reduction, panniculectomy, correction of gynecomastia, brachioplasty, and thigh lift (vertical thigh lift); abdominoplasty, lipectomy, and circumferential abdominoplasty (lower body lift/belt lipectomy) are the three most commonly performed procedures.[9,10,16]

Close attention must be paid to the nutritional status of post-bariatric patients before plastic surgery, especially after malabsorptive procedures, such as RYGB and biliopancreatic diversion with duodenal switch (BPD-DS). Plastic surgery can often constitute major surgery, which requiares the patient to have a good nutritional status. RYGB combines restrictive and malabsorptive components and may be followed by nutritional deficiencies if follow up with a nutritional supplementation routine is not implemented.[17,18] Nutritional complications after malabsorptive weight loss procedures are associated with deficiencies of vitamins, minerals, and certain macronutrients, including protein and essential fatty acids.[18] Furthermore, patients with obesity may also have underlying micronutrient deficiencies, which can worsen in the postoperative period after bariatric surgery.[19,20]
The aim of this meta-analysis is to provide a comprehensive presentation of the literature regarding the nutritional management of patients after bariatric surgery prior to plastic procedures, focusing on recommended nutritional supplementation to help avoid perioperative complications in this patient population.

Methods
An extensive review of related literature included PubMed database articles published between 2000 and 2011. The keywords used for the research were as follows: bariatric surgery, plastic surgery, plastic surgery post bariatric surgery, wound healing, weight loss post major surgery, nutritional deficiencies, protein deficiency, vitamin C and wound healing, and iron and major surgery. Inclusion criteria were articles that related nutrients to bariatric surgery, plastic surgery, and/or wound healing. Exclusion criteria included articles that had similar topics already mentioned by more recent articles, and also articles that did not address topics related to plastic and bariatric surgery.

Results
During this review phase, 54 articles were found, among which 41 were selected, including 18 review articles, nine open-label studies, five transverse studies, three that presented guidelines, two clinical trials, one randomized clinical study, one cohort study, one experimental animal study and one abstract. In addition, two websites of medical societies that contained useful information and three book chapters were examined.

From the research, we concluded that before undergoing plastic surgery, patients should meet certain criteria, including an adequate body mass index (BMI), stabilization of body weight, and an assessment of certain nutrients, as the reduced consumption/metabolism of macro and micronutrients can affect healing.[15]

Optimal timing for plastic surgery post bariatric surgery. The ideal moment for performing plastic surgery should be determined based on the surgical risks for each patient. Plastic surgery should not be performed before the plateau in weight loss has been reached, as subsequent weight loss can cause the patient to develop excess skin in the future.[10] There is no consensus in the literature regarding the duration of the plateau required before performing plastic surgery; however, a period of 4 to 12 months is considered adequate.[13,15,21,22] Stabilization in weight loss usually occurs within 12 to 18 months after bariatric sugery;[13] however, with an increasing time interval between bariatric and plastic surgery, fewer patients may wish to undergo further surgical interventions.[16]

Body weight prior to plastic surgery. Weight loss after bariatric surgery is calculated as the percentage of excess weight loss (EWL). Patients should achieve at least 60 to 70 percent of EWL before weight loss stabilization. EWL of 80 percent or more could lead to extensive losses of muscle mass, nutritional deficiencies, and a reduced resting metabolic rate, so surgery should be avoided in these patients.[23,24]

Body mass index (BMI) is also used to evaluate the extent of weight loss. Pre-plastic surgery BMI is correlated with the postoperative results, including complications that may arise. For example, Kerviler et al[15] observed a significant positive association between the preoperative BMI and the incidence of infection. It is therefore preferable that patients have a BMI less than 32kg/m2 with a BMI less than 28 kg/m2 considered ideal.10 Patients with a BMI above 35kg/m2 may only undergo panniculectomy (i.e., the removal of skin and fat from the abdomen), which does not cause significant undermining of tissues and requires a short operative time.[25] One study[26] showed that patients with a high BMI had significantly more serious complications than patients with lower BMI values. Furthermore, major complications were found among patients who had greater changes in their BMI after EWL and also among patients with a higher pre-bariatric surgery BMI.[26] Kerviler et al[15] suggested that larger decreases in BMI following bariatric surgery actually lead to a lower incidence of minor complications related to necrosis and anastomotic dehiscence.[15] They showed a 40-percent increase in surgical complications among patients with a relatively small reduction in their BMI. Orpheu et al[27] also showed that pre-bariatric surgery BMI correlates with the amount of collagen; the lower the pre-bariatric surgery BMI, the higher the amount of hypogastric collagen (p=0.0048), that suggests a soft skin lacking sufficient collagen fiber network. It is desirable that the majority of weight lost by the patient should be adipose tissue, as a body fat percentage above 32 percent for women and 25 percent for men indicates the risk of obesity-related diseases, including cardiovascular disease, which can affect the success of plastic surgery.[28]

With regard to muscle mass, a loss of 20 percent in the first year after RYGB is common, even with the use of protein supplements.[29,30] This is the maximum acceptable decrease for this parameter at our clinic. Intense muscle depletion is related to protein deficiency. This is important to note because protein is one of the main nutrients needed for healing after surgery and provides other benefits, which we discuss in more detail later in this article.[31,32] Post-plastic surgery, the healing process increases the metabolic rate and muscle consumption, which consumes adipose tissue in particular and, thus, provides amino acids for gluconeogenesis.[19]

Nutritional support for patients undergoing plastic surgery. Routine supplementation for bariatric surgery patients is already well described in the literature. This supplementation consists of a multivitamin-mineral supplement with 200 percent of the daily value added by higher doses of vitamin B12, iron, and vitamin C for menstruating women, and calcium with vitamin D.[18] Patients who have undergone bariatric surgery should receive additional supplementation before plastic surgery as this can constitute major surgery after the patient has already experienced restrictive and malabsorptive components from the initial bariatric procedure.

In addition, nutritional supplementation must be optimized to improve the healing process after plastic surgery. An adequate intake of energy and macronutrients is required for a healing process to progress without complications. Specific nutrients are important to improve wound healing, and, therefore, nutritional supplements must be taken in addition to the routine supplementation.[19] These include protein, essential fatty acids, zinc, iron, vitamin C, and vitamin A. Together, these nutrients can enhance the immune system, improve inflammatory patterns after plastic surgery, prevent skin infections, and improve the healing process.[19,33,34]

Protein. In our analysis, we did not find a consensus regarding the intake of protein at the time when plastic surgery is performed. There is a recommended level of protein intake for the bariatric population, which consists of a protein intake of between 60 and 120g/d or 1.5g/kg of ideal weight to prevent the loss of lean body mass and optimize weight loss.[35,36]

It is noteworthy that a 25-percent increase of protein and calories needs occurs in cases after major plastic surgery procedures.[33,34,37] The healing process increases the metabolic rate, the serum levels of catecholamines, the loss of body water, and protein turnover, which combine to result in a catabolic state, which is a state of breaking down of foods consumed and reserve body tissues in order to obtain energy.[38]

To assess whether protein intake is adequate, the patient might use a food diary to calculate the amount of protein based on standard values for the different types of food consumed.[39] In addition, laboratory tests can evaluate the levels of serum albumin, pre-albumin, and transferrin levels, as many patients post-bariatric surgery may have low levels of these proteins prior to plastic surgery.[10,34] The use of nutritional supplements is indicated for the patient to achieve an adequate daily intake of protein. The consumption of protein-rich foods, containing low levels of carbohydrates and lipids should also be encouraged for the same reason.[39]

After undergoing bariatric surgery, more than 15 percent of patients have a protein intake that is lower than recommended, at 40g/d or less.39 Furthermore, increasing age, along with a wide fluctuation in BMI values after BS, are both factors that are related to levels of protein intake below those recommended.[34] The low intake of proteins, and also of calories in patients post bariatric surgery may be related to food intolerances, smaller gastric capacities, and malabsorption observed in some surgical procedures, such as RYGB and BPD.[35] An adequate protein intake is essential, especially when undergoing plastic surgery, since a low intake of this nutrient can cause anastomotic dehiscence and delayed healing after surgery.[31,32]

Arginine and glucose control. Arginine is an amino acid that merits special consideration in reference to plastic surgery, as it enhances healing by improving the immune system, increasing the synthesis and deposition of collagen, and enables production of nitric oxide. This amino acid also increases the concentration of hydroxyproline and collagen in patients with diabetes.[19]
Patients with diabetes may have a poor immune response, with prolonged reaction times, which delays the deposition of components needed for proper healing. This delayed healing is accompanied by the reduced production of collagen and, in cases of hyperglycemia, is accompanied by a reduction of the benefits provided by vitamin C in the healing process, as this vitamin faces competitive inhibition with glucose during transport.[19] Thus, besides an adequate intake of arginine, glucose control is also indicated in patients with diabetes who will undergo plastic surgery.

Iron. Iron deficiency can affect up to 50 percent of patients pre-bariatric surgery and may continue after surgery, especially after RYGB and BPD procedures. Iron deficiency after bariatric surgery results from digestive changes, a decrease in the production of hydrochloric acid by the stomach, and the malabsorption of nutrients. This diagnosis can be made using laboratory tests, with values of ferritin less than 20ng/mL and serum iron less than 50 μg/dL.[18] Iron is the nutrient most associated with anemia, but vitamin B12 deficiency can cause macrocytic anemia. This is diagnosed when serum levels of vitamin B12 are below 200pg/mL.[18]
In one study, Naghshineh et al[34] found the prevalence of anemia among post-bariatric surgery patients was 24 percent. Furthermore, dumping syndrome, a series of symptoms, such as weakness, diarrhea, and dizziness, which occur due to the rapid arrival and absorption of nutrients with high osmolarity in the jejunum, is associated with anemia prior to plastic surgery.[34] The loss of blood due to plastic surgery can cause anemia or aggravate an already diagnosed case, especially when multiple surgical procedures are performed during a single anesthetic. Iron supplementation may be required to enable the proper formation of erythrocytes, with their key role in the oxygenation of tissues.[22,40] It is, therefore, important to provide supplemental doses between 40 and 65mg of elemental iron, 320mg of fumarate, or twice-daily doses of ferrous gluconate, to ensure the adequate prevention of anemia. In patient cases where iron deficiency has been diagnosed, a supplementation of up to 300mg of elemental iron per day, with the addition of vitamin C to enable the increased absorption of this nutrient, can be given.[17] When oral treatment has failed or in cases of severe anemia, intravenous iron infusion should be considered.18 Moreover, 350μg doses of crystalline vitamin B12 should be given orally.[41]

Vitamin C. Vitamin C increases nonheme iron absorption and also plays an important role in wound healing.[18,19] Vitamin C is an essential cofactor in the synthesis of collagen, proteoglycans, and other components of the intracellular matrix, such as bones, skin, capillaries, and other connective tissues. Vitamin C deficiency delays and impairs wound healing and causes the production of abnormal collagen fibers, as well as changes in the intracellular matrix, as seen in skin lesions, the poor adhesion of endothelial cells, and a reduction in the tension of fibrous tissues.[42] More specifically, vitamin C is necessary for the hydroxylation of proline and lysine residues in procollagen, which is converted into collagen. Hydroxyproline is also necessary for collagen stabilization. Additionally, vitamin C is a powerful antioxidant that can improve neutrophil function and enhance angiogenesis.[19]
A supplementation of 1 to 2g of vitamin C is recommended for any patient with injuries until healing is complete.[33] before undergoing bariatric surgery, it is suggested that patients take a supplement of 750mg of vitamin C. During the post-plastic surgery healing process, a dose of 1 to 2g daily is recommended.[43]

Zinc. Zinc is an essential mineral in all stages of cell repair and healing, as it participates in enzymatic activities, DNA synthesis, cell division, and protein synthesis. Zinc supplementation in the preoperative phase of plastic surgery improves healing, even among individuals who have no sign of zinc deficiency. Stress, fistulas, diarrhea, and injury can lead to a higher probability of zinc deficiency.[44]

Pre-operative zinc supplementation is recommended in cases of proven deficiency. For non-obese patients, a perioperative supplement of between 15 to 30mg/day is administered. In cases of malabsorption, (as in RYGB), this dose may be increased.[44] Thus, after bariatric surgery, particularly in those patients preparing for plastic surgery, a daily supplementation of 40mg is recommended, which is the maximum tolerated amount.[45]

Vitamin A. A deficiency in vitamin A can also affect healing after plastic surgery procedures as this vitamin is an essential factor for improving the immune system. it is also essential for an appropriate postoperative inflammatory response, and a better overall healing process at every stage.[33] For bariatric surgery patients, both before and after undergoing plastic surgery, a supplementation of between 15,000 and 50,000IU/day orally or, in cases of deficiency of this nutrient, 10,000IU/week intravenously can be recommended.[33,36]

Essential fatty acids. Essential fatty acids (EFAs) also play an important anti-inflammatory role and modulate the immune system.[19] In the case of post-bariatric surgery patients, the clinical signs of EFA deficiency that could affect the success of plastic surgery are dry skin, an impaired immune system, anemia, and an increased susceptibility to infections.[41]

A post-bariatric surgery patient should receive between  0.5 to 1.0% of linolenic acid and between 3 to 5% of linoleic acid from energy intake. The EFA intake, therefore, can be ensured with daily supplements of 15mL of flaxseed oil or two capsules of flaxseed oil and two tablespoons of extra-virgin olive oil.[41,46]

Table 1: Recommended prescription of supplements for patients undergoing plastic surgery
following bariatric surgery

Conclusion
Patients who have undergone bariatric surgery may also wish to undergo plastic surgery. From our meta-analysis of this patient population we concluded that attention should be given to whether a patient’s weight loss has stabilized and is complete, which usually occurs between 12 and 18 months following bariatric surgery.[47] The use of nutritional supplements prevents complications during the perioperative period of plastic surgery and should be established by the combined work of dieticians, with the bariatric surgeon, and the plastic surgeon. Certain nutrients should be supplemented without exception during the pre and postoperative period, including protein, iron, vitamin C, zinc, vitamin A and EFAs. More randomized studies among the post-bariatric surgery population are needed to assess the dosage of each supplement for bariatric patients accurately during both of these periods.

Acknowledgment
The authors would like to thank Mr. William Viteli for assisting in the review of this paper.

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