Introduction to Body Contouring after Bariatric Surgery

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.

REFERENCES
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Category: Past Articles, Review