Evaluation of excess skin in Swedish adults 18–59 years of age

"Normal" breast dimensions in obese women-reference values and the effect of weight loss

BACKGROUND

Breast hypertrophy may cause significant suffering, such as back- and breast pain, painful shoulder groves, and eczemas. Furthermore, women with breast hypertrophy may have lower quality of life than women without breast hypertrophy. Although 50% of the women undergoing breast reduction in the US have body mass index (BMI) >30 kg/m2, the current standard of normality is based on studies focusing on women <40 years of age and BMIs <25 kg/m2. This study aimed to present reference values for breast measurements for women with obesity and to investigate the relationship between BMI loss and each breast measurement.

MATERIALS AND METHODS

One hundred and six women underwent laparoscopic Roux-en-Y gastric bypass in Gothenburg, Sweden. The participants' breast anthropometrics were measured before and after bariatric surgery and their perception of the skin on their breasts was measured using the Sahlgrenska Excess Skin Questionnaire.

RESULTS

Breast volume, sternal notch to nipple (SNN) distance, and ptosis increased significantly with increasing BMI. For instance, women with BMIs between 30-34.9 kg/m2 have a mean breast volume of approximately 770 ml, those with BMIs of 40-44.9 kg/m2 have approximately 1150 ml, and those with BMIs above 50 kg/m2 have approximately 1400 ml. Furthermore, the percent change in the respective breast measurements relative to percent BMI change can be predicted, for instance, with a 20% reduction in BMI, the breast volume, SNN-distance, and ptosis decrease by 25%, 4%, and 20% respectively.

CONCLUSIONS

This article presents the first standard of normality for breast anthropometrics in women with obesity and a model for predicting the change in breast anthropometrics relative to BMI.

CLINICAL TRIAL REGISTRATION

This is a longitudinal observation study, registered https://fou.nu/is/gsb/ansokan/49651, No: VGFOUGSB-49651. Trial registry name: "Överskottshud efter överviktskirurgi - dess utveckling samt behov och effekt av plastikkirurgi" ("Excess skin after bariatric surgery - its development and the need and effect of plastic surgery").

SESQ, a patient-reported outcome instrument addressing excess skin; report on the updated version and the validation process

Excess skin after weight loss is perceived as a major problem for the majority of the bariatric patients, between 68 and 90% desire additional reconstructive surgery. However, only about 20% of the patients actually have the possibility to undergo these procedures. Reliable and valid patient-reported outcome instruments, PROM, are required in order to consider the patients' perspective of excess skin when discussing reconstructive surgery. The aim of this study was to present the updated version of Sahlgrenska Excess Skin Questionnaire, SESQ and to report on the validation process. The material for the process to evaluate internal consistency and known group validity was based on four different studies conducted at the Department of Plastic Surgery at Sahlgrenska University Hospital, Sweden. Internal consistency was high in all four groups examined; the normal population, the obese patients, the post-bariatric patients and the post-abdominoplasty patients. Values for Cronbach's alpha were >0.86 in all groups, and the highest value was seen in the obese patients (0.92). Furthermore, regarding known group validity, there were strong significant differences between the answers from the normal population in comparison with most of the other studies. In conclusion, patients thought that the questions in SESQ were easy to understand, that they covered all appropriate aspects of excess skin and the patients did not think that SESQ overlooked any questions or aspects concerning excess skin. SESQ is a valid questionnaire addressing excess skin in post-bariatric patients. The updated version of the SESQ is both accurate and user-friendly.

Translation and validation of a Swedish version of the BODY-Q: a patient-reported outcome instrument for weight loss and body contouring surgery

BODY-Q is self-administered questionnaire that evaluates appearance, function and symptoms related to bariatric- and body contouring surgery. The purpose of this article was to describe the translation process of a Swedish version of BODY-Q and to evaluate its criterion validity to the Swedish questionnaire Sahlgrenska Excess Skin Questionnaire, SESQ.

MATERIALS AND METHODS

BODY-Q was translated according to International Society for Pharmacoeconomics and Outcome Research's guidelines. The test of validity was made between parts which were comparable to SESQ. Both questionnaires were responded by 30 subjects who were suffering from excess skin after massive weight loss following bariatric surgery or dieting.

RESULTS

The correlation between the two questionnaires varied. The parts of BODY-Q evaluating excess skin on the whole body and parts of the body had higher correlations (r_s 0.328-0.766) than the parts evaluating side effects of excess skin and body-image (r_s 0.103-0.574).

CONCLUSION

The Swedish version of BODY-Q has a good criterion validity and can be recommended in the healthcare for patients with excess skin after massive weight loss and for evaluation of the outcomes from reconstructive surgical procedures.

Physical measurements and patients’ perception of excess skin on arms and thighs before and after bariatric surgery

Background

Bariatric surgery is an effective weight loss method for patients with obesity. One side effect of bariatric surgery is uncomfortable excess skin. Much remains to be learned about physical measurements and patients’ subjective perceptions of it. Here, we investigated the pre- to post-bariatric changes in patients’ perception and physical measurements of the skin on the arms and thighs, in order to find possible subgroups especially affected by post-operative excess skin and to identify predicting factors.

Methods

One hundred forty-seven patients eligible for bariatric surgery completed the Sahlgrenska Excess Skin Questionnaire (SESQ) and underwent measurements of their skin before and 18 months after the procedure.

Results

Although most physical measurements decreased post-operatively, many patients reported increased discomfort. We identified one subgroup particularly prone to report excess skin on the arms post-operatively: women with high discomfort from excess skin on the arms and high body mass index (BMI), pre-operatively. Ptosis of the excess skin seems to be a feasible measurement for predicting post-operative discomfort. For every centimetre of ptosis pre-operatively, patients had 1.37- and 1.31-fold higher odds of achieving a score for post-operative discomfort from excess skin on the upper arms and thighs, respectively, of ≥ 6 (on a 0–10 scale).

Conclusions

We identified a subgroup especially affected by discomforting excess skin on arms and thighs after weight loss. Furthermore, we suggest a pre-operative pro-operative ptosis measuring to predict post-operative discomfort level. The result of this study further increases the knowledge of excess skin and should be useful in further improving patient education.

Level of Evidence: Level III, risk / prognostic study.

Excess skin after weight loss following bariatric surgery: focus on the abdomen

BACKGROUND

The majority of postbariatric patients experience major problems from excess skin, with most desiring abdominoplasty.

OBJECTIVES

To present visual assessments and objective measurements of excess abdominal skin; analyze relationships between patient-reported outcomes, objective measurements of excess skin, and visual assessments; and discuss criteria for reconstructive abdominal surgery in public healthcare.

SETTING

An academic hospital in Sweden.

METHODS

This is a secondary analysis of a prospective, longitudinal study that included 200 obese patients undergoing bariatric surgery, with 147 of these patients participating in follow-up 18-months postsurgery. Patients rated their symptoms related to excess skin and quality of life (QoL) according to the Sahlgrenska Excess Skin Questionnaire and EuroQol-5 D before and after bariatric surgery. Abdominal ptosis was measured at different anatomic locations.

RESULTS

Waist circumference and ptosis were significantly reduced at all anatomic locations after weight loss, and abdominal ptosis was significantly larger laterally than at the midline (P < .001). The majority of patients had a ptosis ≥3 cm following bariatric surgery and had significantly more symptoms related to excess skin relative to those reported preoperation (P < .05). Additionally, the number of patients experiencing discomfort from excess skin increased along with increased ptosis size, but the correlation between ptosis size and QoL was low. Reconstructive abdominal surgery was requested by 70% of patients, all having significantly larger ptosis and significantly more symptoms than those not desiring surgery.

CONCLUSION

Criteria for abdominal reconstruction should be based on both patient-reported symptoms and objective measures to ensure more patient-centered care than is possible only using objective measurements.

Presurgical Predictive Factors of Excess Weight Loss After Laparoscopic Sleeve Gastrectomy

PURPOSE

Conditions associated with surgical technique and postoperative lifestyle changes, as well as the characteristics of patients, may affect weight loss following laparoscopic sleeve gastrectomy. In this study, the effects of age, gender, BMI, and excess weight at the time of surgery on weight loss during follow-up were examined.

MATERIALS AND METHODS

Demographic data (age, gender), preoperative BMI, and weight values of the patients were recorded. TWL% and EWL% values of patients were recorded during follow-up at 1st, 3rd, 6th, 9th, 12th, and 18th months. Patients were grouped according to age (AGE1 < 30, AGE2 30-50, AGE3 ≥ 50 years), BMI at the time of surgery (BMI1 ≤ 50, BMI2 > 50 kg/m²), and EW at the time of surgery (EW1 ≤ 60, EW2 > 60 kg). EWL% values obtained in the follow-up visits were compared among the gender, age, BMI, and EW groups.

RESULTS

A total of 456 patients (371 females, 85 males) were operated. Mean EWL% was lower in AGE3 group (p < 0.001). Patients in AGE1 group had the highest mean EWL%, while those in BMI2 and EW2 groups had lower mean EWL% values throughout the follow-up period (p < 0.001). Regression analysis showed that age and BMI were associated with EWL% at all follow-up visits (p < 0.05).

CONCLUSION

Patients with less than 60 kg of excess weight, those with BMI ≤ 50 kg/m² and younger patients may lose weight more effectively following LSG.

Aspects of excess skin in obesity, after weight loss, after body contouring surgery and in a reference population

BACKGROUND

Excess skin is well known after massive weight loss but, there is missing knowledge from various groups.

OBJECTIVES

To describe and compare excess skin in a reference population during obesity, after obesity surgery, and after reconstructive abdominoplasty.

SETTING

University hospital, Sweden.

METHODS

The following 6 groups were included: the reference population, obese adults before obesity surgery, obese adults after obesity surgery, adolescents after obesity surgery, super-obese adults after obesity surgery, and adults after abdominoplasty. All groups filled in the Sahlgrenska Excess Skin Questionnaire (SESQ). Some groups also underwent measurements of ptosis/excess skin on 4 body parts.

RESULTS

All groups scored significantly higher experience of and discomfort from excess skin compared with the reference population. SESQ scores were significantly higher for obese adults (10.5 ± 8.5) and even higher for adults and adolescents (12.3 ± 8.1 versus 14.4 ± 7.7) after obesity surgery compared with the reference population (1.5 ± 3.5). Abdominoplasty resulted in significantly reduced scores (2.9 ± 5.2). Those undergoing obesity surgery and weight loss had significantly less excess skin measured on arms, breasts, and abdomen compared with before surgery, except for the upper arms on the adolescents. Excess skin increased on inner thighs in both age groups after weight loss. Correlations between objectively measured ptosis/excess skin and the patients' experience of and discomfort were .16 to .71, and the highest correlations were found among adolescents.

CONCLUSION

Excess skin is not a problem for the vast majority of the normal population but is linked to obesity and massive weight loss. The SESQ score illustrates major problems related to excess skin both for obese adults and after obesity surgery for adults and for adolescents, who have problems similar to or worse than adults. Abdominoplasty markedly decreases symptoms.

Self-image after bariatric surgery and its relationship to gender, excess skin and health-related quality of life

Introduction: There is limited knowledge about self-image in relation to excess skin after bariatric surgery. The aim of this study was therefore to explore self-image after massive weight loss and its relationship to gender, weight loss, discomfort regarding excess skin and health-related quality of life. Methods: Eighteen months after obesity surgery, 131 patients filled in questionnaires about self-image (Som jag ser mig själv), excess skin (Sahlgrenska Excess Skin Questionnaire, SESQ) and quality of life (EQ-5D and SF-36). In addition, maximal ptosis was measured on their abdomen, arms and thighs. Results: There were no differences in self-image or quality of life between the genders. Participants who scored low discomfort on SESQ had a significantly better overall self-image, in all subscales, compared to those with high discomfort scores (p < .05). They also had a significantly higher quality of life on the EQ-5D VAS (p = .045). Correlations were low, if any, between self-image, excess skin, quality of life and ptosis. There were moderate correlations between the SESQ score and the self-image subscore 'physical well-being', and in self-image and quality-of-life scores. Conclusions: Self-image is lower among those who experience a high degree of discomfort of excess skin after bariatric surgery. Its correlation to weight loss, measured excess skin and quality of life is weak.