Perioperative management of the post-gastric-bypass patient presenting for body contour surgery

Abdominoplasty after massive weight loss. Safety preservation fascia technique and clinical outcomes in a large single series-comparative study

Introduction

Weight loss after bariatric surgery causes very important modifications to the patient's silhouette. Abdominal fat and skin excess reduction are associated with several complications. The most frequent are seroma and hematoma whereas major complications, such as pulmonary embolism, are less frequent. This study aimed to describe our technical procedure for abdominoplasty in patients with massive weight loss after bariatric surgery.

Methods

In total, 196 patients were included. All patients who underwent abdominoplasty classic (group A) and abdominoplasty with the preservation and lift of Scarpa fascia (group B) and with umbilical transposition between May 2018 and May 2021 were included. Patients with concomitant correction of ventral hernia were excluded. Demographic and operative data were analyzed according to comorbidities and postoperative complications.

Results

There were 160 (81.6%) women. The mean age was 43.6 years; the mean weight was 86.7 kg; and the mean BMI was 28.6 kg/m2. Five patients (2.5%) presented postoperative seroma. Four patients (2%) presented partial dehiscence/skin necrosis one of them requiring a revision. Finally, 26 patients presented a postoperative complication, with an overall incidence of 12.6%. The average postoperative hospital stay was 3.6. The rates of seroma were significantly higher in men, patients with a BMI > 30 kg/m2, and aged >50 years.

Conclusion

Preserving Scarpa Fascia during surgical post-bariatric patient procedures reduces the seroma formation and the scar complication and reduces the tension of the inguinal-pubic region with correction of our deformation after weight loss. Improves reducing the drain and reducing seroma incidence suction and hospital stay.

Current Practices and Guidelines for Perioperative Blood Management in Post-Bariatric Body Contouring Surgery: A Comprehensive Review of Literature

With the increase in obesity prevalence, a noticeable increase in bariatric surgeries has been reported in national and international statistics. Therefore, body contouring surgeries have increased to help individuals achieve their desired body shape. Plastic surgeons need to consider potential hematologic complications that may occur in this specific group of patients before performing body contouring surgery. This review illustrates the perioperative medical, laboratory, and management strategies needed to minimize blood loss and blood transfusion requirements during body contouring. Using Google Scholar and PubMed, a comprehensive literature review was conducted to identify articles discussing post-bariatric body contouring perioperative blood management strategies, including the effects of bariatric surgery on hemostasis as well as basic hematology and coagulation. In preoperative blood management, blood investigations aid in the early detection of electrolytes, protein, and vitamin deficiencies and anemia, resulting in the early correction of nutritional deficiencies. In order to reduce postoperative complications, surgical and anesthesia techniques, as well as intraoperative pharmacological therapy, play an essential role. Postoperative blood transfusion and restrictive transfusion thresholds are tailored to the patient's needs and depend on various physiological indicators, such as heart rate, blood pressure, urine output, and laboratory findings, such as acidosis and hematocrit level. Generally, post-bariatric body contouring blood management measures are still lacking, and more research is required to develop standardized guidelines for optimizing patient safety and satisfaction.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Role of Portable Incisional Negative Pressure Wound Therapy (piNPWT) in Reducing Local Complications of Post-bariatric Brachioplasty: A Case-Control Study

Background

Due to the great impact of bariatric surgery on the overweight epidemic, the number of post-bariatric body-contouring procedures is constantly increasing worldwide. The portable incisional negative pressure wound therapy (piNPWT) is a promising medical device for accelerating wounds closure and controlling post-operative complication, which have been shown promising results in post-bariatric population. We aimed to evaluate the role of piNPWT in optimizing wound healing and controlling post-operative complications after a post-bariatric brachioplasty.

Patients and Methods

26 post-bariatric female patients who underwent a brachioplasty followed by either a piNPWT (14 cases) or a standard wound treatment (12 controls) were analyzed. The number of post-operative dressing changes, the rate of local post-operative complications (re-operation, hematoma and serosa development, dehiscence and necrosis), the time to dry as well as the scar quality and hospitalization length were evaluated.

Results

None of the patients prematurely stopped treatment with piNPWT due to intolerance. The piNPWT patient group showed a significant lower healing time as well as a significant reduction of the number of post-operative dressing changes and hospital stay. Despite the scarring process was excellent from the functional point of view in the long term, we noticed a higher rate of hyperchromic scarring at 90 days after surgery.

Conclusion

The piNPWT is a cost-effective and user-friendly medical tool that increase and promote wound healing. We suggest the use of this device in post-bariatric patients who undergo a brachioplasty, especially if there is the need to minimize the number of post-operative dressing changes.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Panniculectomy at the time of bariatric surgery: a propensity score-matched analysis of outcomes in the MBSAQIP database

BACKGROUND

Body contouring in the postbariatric surgery patient improves quality of life and daily function.

OBJECTIVES

To determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers.

METHODS

We examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls.

RESULTS

One hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99-10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02-9.96, P = .046).

CONCLUSION

In select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes.

Review of Insurance Coverage for Abdominal Contouring Procedures in the Postbariatric Population

BACKGROUND

Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population.

METHODS

The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage.

RESULTS

Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415).

CONCLUSIONS

For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.

Sublay or onlay incisional hernia repair along with abdominoplasty: which is better? Long-term results

PURPOSE

Estimation and comparison of results after incisional hernia repair (IHR) modo onlay or sublay with abdominoplasty in patients who lost the weight following Roux-en-Y Gastric Bypass (RYGB). Analysis and comparison of changes in quality of life (QL) of these patients prior to RYGB, before and after simultaneous IHR and abdominoplasty.

METHODS

Clinical analysis involved 40 patients with abdominal disfigurement (following RYGB and massive weight loss) after one-time IHR sublay method with abdominoplasty-group 1 or IHR onlay method with abdominoplasty-group 2. We evaluated postoperative results and long-term QL changes (DAS24, SF-36 scales).

RESULTS

We noted abnormal wound healing (2), pneumonia (3) and dysesthesia (3) in patients from group 1, and abnormal wound healing (2), seroma (2), pneumonia (2), and dysesthesia (4) in group 2. Quality of life was improved in the functional, esthetic and psychological aspects.

CONCLUSIONS

One stage incisional hernia repair by onlay as well as sublay method with abdominoplasty are safe surgical methods improving the functioning of patients after major weight loss following RYGB. Sublay hernia repair and abdominoplasty was connected with longer time of the: operation, drainage, analgesic agents use, time to mobilization and to full oral diet than the onlay method. Significant improvement of the quality of life was noted after every subsequent step of surgical treatment in both groups. Reduction of the risk of BMI re-growth after bariatric surgery is related to the need for constant, specialized care for these patients at every stage of follow-up after bariatric surgery.

Autologous Gluteal Augmentation with the Moustache Transposition Flap Technique

Massive weight loss patients and aesthetic patients can present with significant gluteal contour abnormalities. Gluteal ptosis, skeletal deformities, severe platypgia, and a paucity of donor fat for autologous transfer are common problems. Excisional procedures are used to treat massive-weight-loss contour abnormalities. These procedures present an opportunity to address severe gluteal deformities using autologous tissue augmentation. With a working knowledge of the relevant anatomy, sound surgical technique, and meticulous postoperative care, autologous gluteal autoaugmentation with circumferential body lift/excisional buttock lift using the "Moustache" flap technique will enhance massive weight loss body contouring outcomes and improve patient satisfaction.

Distinctive microbiomes and metabolites linked with weight loss after gastric bypass, but not gastric banding

Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) are anatomically different bariatric operations. RYGB achieves greater weight loss compared with LAGB. Changes in the gut microbiome have been documented after RYGB, but not LAGB, and the microbial contribution to sustainable surgical weight loss warrants further evaluation. We hypothesized that RYGB imposes greater changes on the microbiota and its metabolism than LAGB, and that the altered microbiota may contribute to greater weight loss. Using multi-omic approaches, we analyzed fecal microbial community structure and metabolites of pre-bariatric surgery morbidly obese (PreB-Ob), normal weight (NW), post-RYGB, and post-LAGB participants. RYGB microbiomes were significantly different from those from NW, LAGB and PreB-Ob. Microbiome differences between RYGB and PreB-Ob populations were mirrored in their metabolomes. Diversity was higher in RYGB compared with LAGB, possibly because of an increase in the abundance of facultative anaerobic, bile-tolerant and acid-sensible microorganisms in the former. Possibly because of lower gastric acid exposure, phylotypes from the oral cavity, such as Escherichia, Veillonella and Streptococcus, were in greater abundance in the RYGB group, and their abundances positively correlated with percent excess weight loss. Many of these post-RYGB microorganisms are capable of amino-acid fermentation. Amino-acid and carbohydrate fermentation products-isovalerate, isobutyrate, butyrate and propionate-were prevalent in RYGB participants, but not in LAGB participants. RYGB resulted in greater alteration of the gut microbiome and metabolome than LAGB, and RYGB group exhibited unique microbiome composed of many amino-acid fermenters, compared with nonsurgical controls.

Objective Assessment of Facial Rejuvenation After Massive Weight Loss

BACKGROUND

While the literature is replete with articles about body contouring after bariatric surgery, little information exists regarding the outcomes of facelift following massive weight loss (MWL). A case report and a technique article are the only sources available addressing this issue. This pilot study objectively examines the effects of MWL in the cervicofacial region and results after facelift.

METHODS

A retrospective review of seven patients who underwent facelift after MWL (>100 pounds) was performed. Patient's change in appearance was objectively evaluated using an apparent age model. Forty blinded reviewers assessed pre- and postoperative photographs of seven MWL and eleven non-MWL female patients. The reviewers estimated the apparent age for each subject. Reduction in apparent age was calculated by comparing patient's apparent age against actual age.

RESULTS

The preoperative apparent age of MWL patients was 5.1 years older than their actual age (p < 0.02) compared to the increased preoperative apparent age of 1.2 years in non-MWL subjects (p > 0.05); suggesting MWL patients appear older than their actual age. Post-operatively, the apparent age reduction in MWL patients was 6.0 years; and their apparent age after surgery was 0.9 year less than their actual age (p > 0.05). In contrast, the control group exhibited an apparent age reduction of 5.4 years and a postoperative apparent age 4.2 years younger than their actual age (p < 0.01). Apparent age reduction was not significantly different for the two groups (p > 0.05). Age, BMI, and follow-up were similar between groups (p > 0.05).

CONCLUSIONS

MWL may accelerate apparent cervicofacial aging. Facelift following MWL enhances cervicofacial appearance and significantly reduces apparent age. We hope this study stimulates further interest in the study of facial esthetics in this increasing population.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Obesity and surgical wound healing: a current review

Objective. The correlation between obesity and deficient wound healing has long been established. This review examines the current literature on the mechanisms involved in obesity-related perioperative morbidity. Methods. A literature search was performed using Medline, PubMed, Cochrane Library, and Internet searches. Keywords used include obesity, wound healing, adipose healing, and bariatric and surgical complications. Results. Substantial evidence exists demonstrating that obesity is associated with a number of postoperative complications. Specifically in relation to wound healing, explanations include inherent anatomic features of adipose tissue, vascular insufficiencies, cellular and composition modifications, oxidative stress, alterations in immune mediators, and nutritional deficiencies. Most recently, advances made in the field of gene array have allowed researchers to determine a few plausible alterations and deficiencies in obese individuals that contribute to their increased risk of morbidity and mortality, especially wound complications. Conclusion. While the literature discusses how obesity may negatively affect health on various of medical fronts, there is yet to be a comprehensive study detailing all the mechanisms involved in obesity-related morbidities in their entirety. Improved knowledge and understanding of obesity-induced physiological, cellular, molecular, and chemical changes will facilitate better assessments of surgical risks and outcomes and create efficient treatment protocols for improved patient care of the obese patient population.

Hematological variables and iron status in abdominoplasty after bariatric surgery

BACKGROUND

Abdominoplasty, the treatment for abdominal wall deformity stemming from weight loss after bariatric surgery, can cause postoperative anemia. Moreover, bariatric surgery has been associated with iron deficiency, which by itself can compromise erythropoiesis. The objective of this research is to describe the development of anemia after postbariatric abdominoplasty.

METHODS

The study group consisted of 32 adult women who had received bariatric surgery. Treatment group included 20 patients who were undergoing postbariatric abdominoplasty. Control group included 12 patients waiting for abdominoplasty. Values of hemoglobin, reticulocytes, iron, ferritin, and the transferrin saturation were obtained on the evening before abdominoplasty and during the first, fourth, and eighth postoperative weeks. Hemoglobin was measured at 48 h.

RESULTS

Mean hemoglobin levels for treatment group decreased from 12.98 to 10.8 g/dL after 48 h, increased on day 7 to 11.53 g/dL, but did not increase further after day 7. The reticulocyte number increased in the first week. Serum iron and transferrin saturation index fell during the first week and remained low. Ferritin levels increased non-significantly from 29.77 to 37.24 ng/mL at week 1, then fell until they were decreased (16.44 ng/mL) by day 56.

CONCLUSIONS

As expected, hemoglobin fell after abdominoplasty. However, after a one-third recovery of hemoglobin concentrations by week 1 postoperative, they failed to return to preoperative levels by the eighth week. Additionally, by the eighth postoperative week, 45 % of abdominoplasty patients had developed an iron deficiency and hemoglobin deficit that was higher than that of patients who maintained normal iron stocks.

Increased intraoperative bleeding in patients undergoing abdominoplasty after gastroplasty is not due to coagulopathy

BACKGROUND

Abdominoplasties carried out in patients previously underwent gastroplasty present high rates of complications, including increased bleeding in the intra- and postoperative periods.

METHODS

This study evaluated bleeding, coagulation parameters (coagulogram, dosage of fibrinogen, FII, FV, FVII, FVIII, FIX, FX, and FXII), and thromboelastography in two groups of women who underwent abdominoplasties: a group with a history of gastroplasty by the Fobi-Capella technique (group I) and the other group without a history of obesity (group II). Analyses were performed before, during, and after each surgical procedure. Vitamins K and C were also dosed. Bleeding was measured by counting and weighing compresses at the end of each surgery, and the withdrawn surgical specimens were weighed.

RESULTS

Statistically, group I patients had more bleeding than group II in all evaluated operative periods (p = 0.007). There was no significant change in the coagulogram or decrease in coagulation factors that could be associated with increased bleeding in any of the analyzed groups. Thromboelastography, which provides a comprehensive analysis of thrombin generation and of hemostasis in real time, did not differ between groups. Vitamin K was significantly increased in group I patients (p = 0.019). The weight of the surgical specimens removed was significantly higher in group I (p = 0.007) and there was correlation of the weight with the degree of bleeding.

CONCLUSIONS

The results of this study demonstrate an increase of bleeding during the intraoperative period of abdominoplasty in patients with a history of gastroplasty that it is not due to changes in hemostasis.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Changes in dermal histomorphology following surgical weight loss versus diet-induced weight loss in the morbidly obese patient

INTRODUCTION

Patients with postgastric bypass and diet-induced weight loss present to the plastic surgeon for various body contouring procedures. Gross differences in skin dermal elasticity may exist between these populations; however, studies evaluating histologic differences are lacking. This prospective study aims to evaluate histomorphologic differences in morbidly obese patients following surgical versus diet-induced (nonsurgical) weight loss. Further, we aim to elicit if postoperative complications are correlated with the mechanism of weight loss and potential histomorphologic differences.

METHODS

Defined infraumbilical skin specimens were collected during abdominal contouring procedures following weight loss achieved through surgical or nonsurgical means. Specimens were stained for elastic fiber content and morphology, collagen deposition, and inflammation. All sections underwent evaluation for quality and quantity of elastic fibers, collagen architecture, and presence of inflammation in the context of age-matched controls. Histomorphological results were compared between the 2 groups and subanalyzed according to clinical variables and postbody contouring wound complications.

RESULTS

Between July 2008 and December 2010, 30 consecutive patients with significant weight loss (17 surgical, 13 nonsurgical) underwent a panniculectomy (n = 15), abdominoplasty (n = 13), and lower body lift (n = 2), with an average age of 48.3 ± 11.10 years and a body mass index of 39.23 ± 13.65 kg/m. Demographic and clinical variables were not statistically significant between the 2 groups. Blinded histologic evaluation revealed a trend toward normal elastic fiber appearance (P = 0.255), increased wound complications (P = 0.546), and mild inflammation (P = 0.462) in the surgical group. Analysis of dermal histomorphology correlating with wound complications was not statistically significant at follow-up (4.76 ± 5.55 months). Interestingly, there was a persistent inflammatory component in both groups when compared with age-matched controls.

CONCLUSIONS

Although the differences in histomorphology between the surgical and nonsurgical weight loss groups did not reach statistical significance, the results demonstrated an existence of weight loss-induced histomorphological skin changes that may impact future studies. The study did not demonstrate a relationship between dermal histomorphology and postoperative wound complications, suggesting that aberrant healing in body contouring procedures involves a multifactorial process.

Prospective assessment of nutrition and exercise parameters before body contouring surgery: optimizing attainability in the massive weight loss population

BACKGROUND

A lower body mass index at the time of body contouring surgery can optimize surgical options and, ultimately, aesthetic results. With increased emphasis on preoperative evaluation of the massive weight loss patient, the interrelationships between nutrition and exercise on body mass indices have not been well defined.

METHODS

One hundred thirty-three consecutive massive weight loss patients presented for body contouring. Two-week food logs, weekly exercise regimens, and body mass indices were measured. Outcome variables were assessed by univariate and multivariate analysis.

RESULTS

One hundred fifteen women and 18 men presented, with a mean age of 46.5 +/- 11.0 years, a maximum body mass index of 52.8 +/- 10.6 kg/m2, current body mass index of 32.4 +/- 8.6, change in body mass index of 20.4 +/- 6.5, daily protein intake of 56.9 +/- 18.5 g, and mean exercise of 3.7 days/week. The mean change in body mass index for the bariatric surgery group was 20.9 +/- 6.4 versus 15.9 +/- 6.8 for the self-weight loss group (p = 0.01). Age correlated directly with current body mass index (p = 0.0031) and inversely with exercise (p = 0.0003). Change in body mass index was related to younger age (p = 0.0455), maximum body mass index (p < 0.0001), and bariatric surgery (p = 0.0016), but not protein intake. Exercise five or more times per week was associated with a larger change in body mass index and lower current body mass index (p < 0.0036) than exercising two or fewer times per week (p = 0.0292).

CONCLUSIONS

Frequent exercise optimizes body mass index at the time of presentation for body contouring surgery. Further evaluation of the elements of diet will be required to determine its role. Thus, comprehensive post-bariatric surgery or lifestyle programs that promote exercise may increase surgical options and optimize results in body contouring surgery.

Body mass and surgical complications in the postbariatric reconstructive patient: analysis of 511 cases

OBJECTIVE

To analyze the impact of body mass indices on postbariatric reconstructive surgery complications.

BACKGROUND

An increasing number of patients are presenting after massive weight loss due to bariatric surgery or diet and exercise. Many of these patients have residual obesity, which may compromise outcomes.

METHODS

449 patients were enrolled in a prospective registry over 6 years. Measures included medical complications and comorbidities. All cases were analyzed together as well as in two subgroups: single procedure cases (Group I) and multiple procedure cases (Group II).

RESULTS

449 patients (407 female, 42 male) with a mean age of 44.5 +/- 10.3 underwent 511 separate operations. Mean pre-weight loss BMI (Max BMI) was 51.6 +/- 9.5 kg/m2, post-weigh loss BMI (Current BMI) was 29.3 +/- 5.0 and the DeltaBMI was 22.3 +/- 7.5. For all cases (n = 511), the presence of a surgical complication was directly related to Max BMI (P = 0.002) and DeltaBMI (P = 0.002) but not Current BMI.Group I consisted of 194 single procedure cases. Complications in Group I were related to Max BMI (P = 0.006) and Current BMI (P = 0.02) but not DeltaBMI. Max BMI impacted infections (P = 0.003) while Current BMI impacted dehiscence (P = 0.009) and infections (P = 0.03). Group II consisted of 317 cases with only DeltaBMI directly related to overall complications (P = 0.01).

CONCLUSIONS

Body mass indices influence complications in postbariatric reconstructive surgery. Current BMI may impact complications in single-procedure cases, but appears to play less of a role in larger cases. Careful patient selection, assessment of surgical complexity, and recognition of the particular risks increased by residual obesity can help to optimize outcomes in this patient population.

Implications of weight loss method in body contouring outcomes

BACKGROUND

Patients frequently present for body contouring after massive weight loss resulting from bariatric procedures or diet and exercise. The authors investigated whether body contouring complications vary by weight loss method.

METHODS

Four hundred forty-nine patients (511 cases) were entered into a prospective registry. Diet and exercise patients were matched to bariatric patients based on identical procedures performed. Conditional logistic regression was used to test for differences between groups. One-to-one matching was then performed by nearest neighbor matching to the most similar patient who underwent bariatric procedures based on sex, age, and body mass index. The t test was used to compare matched patients.

RESULTS

Twenty-nine patients (6.5 percent) lost weight exclusively through diet and exercise. They had significantly higher preoperative hematocrit (p = 0.02) and hemoglobin (p = 0.05), and tended to have multiple procedures performed at the same time, higher absolute complication rates, and significantly higher infection rates (p = 0.03). When matched to 191 bariatric patients based on procedures performed, diet and exercise patients had a higher complication rate that did not reach significance (odds ratio, 1.5; p = 0.28). One-to-one matching resulted in 34 procedure-matched pairs with nonsignificant trends toward better nutrition and more complications in diet and exercise patients.

CONCLUSIONS

Infection rates were higher in patients who had body contouring after massive weight loss from diet and exercise versus bariatric procedures. When matched, despite lower nutrition markers, patients treated with bariatric procedures had outcomes similar to those of diet and exercise patients. We did not find evidence for an association between weight loss method and risk in the body contouring patient.

The desire for body contouring surgery after bariatric surgery

BACKGROUND

Obesity has become far more prevalent over the last few decades. In parallel, bariatric surgery has been increasingly utilized as a method of treatment. This appears to be having an impact on the rate of body contouring surgery for hanging redundant skin after the massive weight loss that usually results from bariatric surgery. Little literature is available addressing how frequently patients who have undergone bariatric surgery receive or desire body contouring surgery or regarding how satisfied these patients are with the hanging skin in certain body areas.

METHODS

Seventy individuals (out of 250 who were mailed the questionnaire) who had undergone Roux-en-Y gastric bypass surgery 6-10 years previously completed a questionnaire, which obtained information regarding their experiences with as well as their desire for body contouring surgery and more general body area satisfaction.

RESULTS

Thirty three of the seventy patients reported having undergone a total of 38 body contouring procedures. The most common were abdominoplasties (24.3%), breast lifts (8.6%), and thigh lifts (7.1%). However, subjects were not uniformly satisfied with body areas that had undergone body contouring surgery; some found the areas unattractive. The majority of patients, at least to some extent, desired body contouring surgery, often in several areas, most notably the waist/abdomen, rear/buttock, upper arms, and chest/breast.

CONCLUSION

Paralleling the increasing use of bariatric surgery is an increasing desire for body contouring surgery. Most patients desire body contouring surgery after bariatric surgery. However, third party payors usually do not reimburse for such procedures.

[Current concepts and trends in post-bariatric plastic surgery]

The epidemic-like increase of obesity in all western countries is associated with a growing incidence of morbid obesity. Here, efficient and lasting weight loss is mostly obtained by surgical interventions today performed in a reliable and safe manner. In that way comorbidities associated with obesity can be reduced or abolished. Treating the sequelae of bariatric surgery, with frequent massive weight loss and generalized skin excess, is challenging for the plastic surgeon. The goal is to restore a normal body contour as a prerequisite for complete psychosocial integration of the patients, who are often stigmatized by their outward appearance not only before but also after the weight loss. The present work provides an overview of current concepts and trends in post-bariatric plastic surgery.

Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap

The reconstruction of breast and upper-body deformities in massive weight loss (MWL) patients presents specific challenges to the plastic surgeon. In addition to significant breast ptosis and loss of breast volume, bariatric patients also have excessive lateral axillary and posterior truncal tissue that may require dermolipectomy for correction. A wise-pattern mastopexy was designed with a pedicled fasciocutaneous flap based on the intercostal artery perforators (ICAP) to correct breast ptosis, to restore breast volume, and to eliminate redundant upper truncal tissue. Five MWL patients underwent mastopexy with ICAP flap augmentation. All patients had stable and esthetically pleasing results 1, 3, and 6 months postoperatively. There were no complications of infection, wound dehiscence, seroma, or hematoma. Furthermore, there was no evidence of flap loss or tissue necrosis. Mastopexy with autologous augmentation using the ICAP flap was found to be a reliable method of breast reconstruction in the MWL patient.

Completing the Metamorphosis

Postbariatric body contouring is an expanding and rapidly evolving specialty within plastic surgery. To best address the many clinical issues related to the safe and effective care of the postbariatric patient, the authors have established a dedicated multidisciplinary treatment center. Team building efforts have brought together attending plastic surgeons who specialize in body contouring, nurses focused on body contouring after weight loss, and an administrative staff well trained in the issues related to managing these specific types of cases. Through core partnerships, nutritionists, lifestyle counselors, and psychologic professionals are present in the clinic to evaluate patients alongside the plastic surgeon. A dedicated physician assistant and body-contouring fellow work in both the clinic and the operating room (OR). This team approach has allowed for the establishment of defined screening procedures and patient care algorithms. Outreach and patient education initiatives have allowed the center to forge strong alliances with the regional bariatric surgeons and make patients aware of the role of plastic surgery as they start the process of weight loss. A strong research mission is demonstrated by an IRB-approved clinical registry and database that facilitate outcomes studies.

Autologous Gluteal Augmentation With Circumferential Body Lift in the Massive Weight Loss and Aesthetic Patient

Massive weight loss (MWL) patients have unique and severe gluteal deformities that demand alternative body contouring solutions because they are rarely candidates for gluteal implants. Techniques for autologous gluteal augmentation (AGA) with circumferential body lift (CBL) are offered as a solution to this problem. Experience with these techniques will allow surgeons to extend AGA to other aesthetic patients presenting with flattened buttocks. Flap indications, surgical planning, techniques,results, complications, and postoperative management are discussed.