Managing the Body Contour Concerns of the Post-Bariatric Patient

by Joseph F. Capella, MD, FACS

Dr. Capella is the Chief of the Division of Post Bariatric Surgery in the Department of Plastic Surgery at Hackensack University Medical Center. He is certified by the American Board of Plastic Surgery and is a member of the American Society of Plastic Surgeons.

Many individuals who have achieved massive weight loss either secondary to bariatric surgery or as a result of lifestyle changes are eager to have body contour concerns addressed. Patients often seek both functional and aesthetic improvement. Invariably, plastic surgery plays a critical role in this process. The approach taken by the plastic surgeon is often influenced by many factors, including patient goals, surgeon preference, patient finances, and, of course, patient health. Careful planning on the part of the plastic surgeon will diminish the likelihood of complications and improve results. For most patients, more than one operation is necessary for complete rehabilitation.

Patient Concerns
Following massive weight loss, men and women present with similar but also somewhat different concerns, which, particularly with women, may vary with age. Women of childbearing age often present with the primary complaint of excess skin along the lower abdomen and hair-bearing pubic area, and excess skin and cellulite along the medial and lateral thighs. A sagging buttocks may also be of concern as is excess fat in any of these areas, but most frequently the mons pubis, lateral and medial thighs, and knee region.[1] Other complaints often include sagging and deflated breasts and excess skin along the arms, axilla, subaxillary region, and back. Older women may present with their arms as being their greatest and perhaps only concern. Men in general have less excess tissue following massive weight loss than women and usually do not present for body contouring unless their highest weight prior to weight loss was more than 350lbs. Men have similar complaints regarding the lower abdomen, mons pubis, and medial thighs. In addition, men often have complaints about lipodystrophy and excess skin along the hip region. Men, however, much less commonly complain about excess skin or fat at the buttocks or anterior, lateral, or posterior thighs. Sagging breasts and excess skin along the arms, axilla, subaxillary region, and back can be of concern for men, but is of less frequency than women. The functional concerns of both men and women usually include intertriginous dermatitis along the lower abdomen and on occasion the buttock cleft, periumbilical region, and medial thigh areas.[2] On the upper body, women may complain about intertriginous dermatitis along the inframammary fold (IMF) and folds extending into the subaxillary region.

Patient Selection
Careful patient selection is an essential component of post-bariatric body contouring. Candidates for surgery should be at a stable weight for at least several months prior to undergoing a procedure. The risk for an early recurrence of skin and soft laxity exists if patients go on to lose a significant amount of weight following body contouring surgery. A stable weight is achieved at different times depending on the bariatric procedure. Following gastric bypass, this may range from 1 to 2 years depending on pre-bariatric weight. Weight loss following gastric bypass and other restrictive and malabsorbtive procedures, such as biliopancreatic bypass, tends to be quite rapid during the first 8 to 12 postoperative months.[3,4] Weight loss following purely restrictive procedures, such as vertical banded gastroplasty and gastric banding, tends to be less and somewhat slower, with weight loss achieved over periods of as long as three years.[5,6] Patients who present four or five years following bariatric surgery may report that they are no longer at their lowest weight. This is quite common since most individuals following bariatric surgery have gained 5 to 10 percent of the excess weight that they had lost at this time. Rather than suggest that they return to their lowest post-bariatric weight, I recommend that they remain at a weight that they are able to maintain over the long term. Returning to their lowest post-bariatric weight is often extremely difficult to achieve and even more difficult to maintain over an extended period of time. Weight gain following body contouring surgery nearly always adversely affects aesthetic outcome, whereas mild weight loss usually does not. In my practice, age itself is usually not a factor in patient selection. However, morbidly obese individuals who have undergone bariatric surgery in the fifth or six decades of life and beyond often have developed some degree of degenerative arthritis, making ambulation following some body contouring procedures more challenging. The risk of limited ambulation should be considered in patient selection.

Anemia, electrolyte imbalances, and mineral deficiencies can be a concern for patients following bariatric surgery, particularly menstruating women and those who have undergone malabsorptive procedures, i.e. gastric bypass and biliopancreatic bypass. The anemia is usually secondary to poor absorption of both iron and folate.[7] I encourage patients to take an iron supplement and daily multivitamins. Severely anemic patients are referred to a hematologist. My preference is for patients to have a hemoglobin of at least 10g/dL for major procedures. I have not suggested that patients bank their own blood prior to procedures, as this is of limited utility in an already anemic individual. Candidates who have undergone biliopancreatric bypass are more likely to have imbalances relating to electrolytes and mineral deficiencies. These individuals require closer evaluation. Patients not recovering normally from bariatric surgery, i.e. frequent vomiting, diarrhea, difficulty maintaining a stable weight, should be referred to their bariatric surgeon for reevaluation.

Sequence and Combination of Procedures
Over the course of my career, I have developed a preference for sequencing and combining procedures in the post-bariatric patient. Safety is of course paramount; however, significant consideration is also given to factors such as vectors of tension, expedience, and patient finances. Understandably, most individuals will request that their concerns be addressed in the least amount of time, the fewest number of procedures, and for the lowest cost. Candidates are usually active and employed and wish to return to their normal lifestyle as soon as possible. Post-bariatric body contouring is usually not covered by insurance and thus represents a significant financial burden for most. In most instances, having multiple procedures performed simultaneously is a more financially feasible option and leads to less time out of work. Nevertheless, choosing the appropriate sequence and combination of procedures for each individual patient is critical to maximizing safety, aesthetics, and cost.
My preference is to perform a body lift first as a single procedure, on appropriate candidates. These are usually individuals with a body mass index of less than 35 and who are otherwise healthy. A body lift is a circumferential procedure that incorporates an abdominoplasty, thigh, and buttock lift.[8] The procedure greatly affects the back and chest and to some degree the medial thighs (Figure 1). An abdominoplasty alone in the massive weight loss patient usually leads to unsatisfactory results. Thigh and buttock concerns are not addressed by this procedure and standing cones or “dog ears,” which are clumps of skin at the end of a scar, are a frequent complaint (Figure 2). Performing a body lift first not only effectively addresses the abdomen, thighs, and buttocks, but may eliminate the need for a formal medial thigh lift in some patients (Figure 3) and prepare other patients for an effective medial thigh lift (Figure 4). My preference is not to perform a medial thigh concomitantly with a body lift even when one is likely to be necessary.[8] The tension vectors at the medial thighs in a body lift procedure are directed upward and outward (Figure 5). On the other hand, the tension vectors at the thighs for a medial thigh lift with a vertical component are directed inward. These conflicting vectors may compromise the results of either procedure. My preference for performing a body lift first also relates to the upper body. The effect of the body lift on the back and flank areas is often dramatic (Figure 6). Both lower and even upper back rolls can be improved upon or eliminated. Often, any remaining back rolls following a body lift can then be addressed by upper body work and in nearly all instances without placing a scar across the back.

Following an initial body lift, patients are then good candidates for upper body contouring. The majority of woman and many men following massive weight loss have sagging and deflated breasts, excess soft tissue along the axilla and subaxillary region (flanks), and excess soft tissue along the arms. My preference is to address each of these concerns as a single procedure: bilateral mastopexy, flankplasty, and brachioplasty (Figure 7). The procedure results in a scar that extends from the medial aspect of the IMF on either side to the medial epicondyle. The concept, described by Pitanguy, creates a more aesthetic relationship between the nipple areolar complex (NAC) and the IMF, removes excess soft tissue from the flank and axilla, and corrects the deformity of the arm.[9] The continuous scar across the flank and axilla allows for a significant amount of tissue to be removed from this area without the concern for a “dog ear.” While this procedure serves to restore a normal relationship between the NAC and the IMF, it does not address the concern for breast deflation that some women have. Invariably performing a mastopexy alone will decrease a woman’s cup size, particularly in the post-bariatric population. While many women are pleased with a mastopexy alone, some would prefer to be larger or have great upper pole fullness. For a part of my career, I performed a single-staged augmentation/mastopexy on most women. I found that the revision rate was directly correlated with the degree of ptosis with virtually all women with grade III ptosis needing a revision mastopexy.[10] My preference is now to stage women with breast ptosis desiring larger, fuller breasts. The breast augmentation follows mastopexy by approximately four months.

All Factors Considered
The choice you ultimately make on how to address the post-bariatric patient should of course consider safety, patient goals and finances, and your preferences. A plastic surgeon’s experience and level of help will also factor greatly in this decision process. In my own practice, for a healthy patient not significantly constrained by time or finances, I  recommend a body lift first, to then be followed—not before three months—by an upper body lift (bilateral mastopexy, flankplasty, and brachioplasty). If needed, four months later a medial thigh lift and/or breast augmentation is performed. Usually patients do care about finances and are constrained by time. For this reason, I may perform a body lift and  mastopexy as a first stage on a woman desiring larger fuller breasts, and then follow with a breast augmentation and possibly brachioplasty and medial thigh lift as a second stage. On a select group of healthy and motivated patients, usually with BMIs of less than 28, I consider performing a body lift with an upper body lift. My data from working with the post-bariatric population suggest that, along with smoking, BMI at the time of body contouring and the highest BMI achieved prior to weight loss are most closely correlated with complications following body contouring.[8] As such, BMI factors greatly in my decision on how to approach the post-bariatric patient.

Conclusion
The extent and degree of deformity in the post-bariatric patient provides the possibility for plastic surgeons to greatly improve the quality of life for many individuals. An optimum aesthetic and functional outcome will depend greatly on careful patient assessment and selection and the proper choice and order procedures.

References
1.    Capella JF. Approach to the lower body after weight loss. In Rubin JP, Matarasso A, eds. Aesthetic Surgery after Massive Weight Loss. Philadelphia: Elsevier; 2007:69–99.
2.    Capella JF, Oliak DA, Nemerofsky RB. Body lift: an account of 200 consecutive cases in the massive weight loss patient. Plast Reconstr Surg. 2006;117:414.
3.    Capella JF, Capella RF. An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity. Am J Surg. 2002;183:117–123.
4.    Marceau S, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947–954.
5.    Chapman AE, Kiroff G, Game P, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery. 2004;135:326–351.
6.    Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass? Am J Surg. 1996;171:74–79.
7.    Brolin RE. Metabolic deficiencies and supplements following bariatric operations. In: Martin L, ed. Obesity Surgery. New York: McGraw-Hill: 2004;275–300.
8.    Capella JF. Body lift. Clinics Plast Surg. 2008;35:27–51.
9.    Pitanguy I. Aesth Plast Surg. 1980;35:27–51.
10.    Aly AS, Capella JF. Staging, reoperation, and treatment of complications after body contouring in the massive-weight-loss patient. In: Grotting J.C. ed. Reoperative Aesthetic and Reconstructive Plastic Surgery, Second Edition. St. Louis: Quality Medical Publishing: 2007;1701–1740.

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