An Anthropometric Classification of Body Contour Deformities After Massive Weight Loss

Panniculus Retractor Use for Visualization of Fetal Anatomy: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether use of a panniculus retractor device for pregnant patients with body mass index (BMI) 40 or higher and a panniculus improves the completion rate of the fetal anatomic examination.

METHODS

This was a randomized trial in which eligible patients with BMI 40 or higher and a panniculus were randomized to undergo their detailed fetal anatomic examination with a panniculus retractor device in place compared with usual care. The primary outcome was the completion rate of 16 prespecified views from the anatomic examination. Secondary outcomes included completion rate of all 64 views from our institution's detailed anatomic examination, duration of examination, major fetal anomaly detection rate, depth from the skin to amniotic cavity before and after retractor placement, patient and ultrasonographer satisfaction, and prespecified adverse events. We assumed a baseline completion rate of 23% for the primary outcome and targeted a twofold improvement with 80% power and two-sided α of 0.05, which resulted in a sample size of 132 participants. The goal enrollment was increased to 150 participants to account for potential dropout. Statistical tests included the Student's t test, χ 2 , and relative risks (RRs) as appropriate.

RESULTS

From March to July of 2023, 150 participants completed the study: 74 in the retractor group and 76 in the usual care group. Baseline characteristics were similar between groups except for panniculus grade. The completion rate of 16 prespecified views was 25.7% (19/74) in the retractor group and 31.6% (24/76) in the control group (RR 0.81, 95% CI, 0.49-1.35). There were no significant differences between groups for any of the secondary outcomes. Patient satisfaction and ultrasonographer satisfaction were similar between groups.

CONCLUSION

Use of a panniculus retractor device during the fetal anatomic examination for patients with BMI 40 or higher and a panniculus was well tolerated by patients and ultrasonographers but did not improve the completion rate of 16 prespecified fetal anatomic views.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT05764408.

Factors Associated with Excess Skin After Bariatric Surgery: a Mixed-Method Study

PURPOSE

After metabolic and bariatric surgery (MBS), many patients have excess skin (ES), which can cause inconveniences. Identifying factors related to ES quantity and inconveniences is crucial to inform interventions. The aim of this study was to identify sociodemographic, physical, psychosocial, and behavioral factors associated with ES quantity and inconveniences.

MATERIALS AND METHODS

A mixed-method study with a sequential explanatory design was conducted with 124 adults (92% women, Mage 46.5 ± 9.9 years, Mtime post-MBS 34.2 ± 27.6 months). During phase I, ES quantity (arms, abdomen, thighs) and inconveniences and sociodemographic, anthropometric, clinical, and behavioral outcomes were assessed. In phase II, 7 focus groups were performed with 37 participants from phase I. A triangulation protocol was completed to identify convergences, complementarities, and dissonances from quantitative and qualitative data.

RESULTS

Quantitative data indicate only ES quantity on arms was associated with ES inconveniences on arms (r = .36, p < .01). Total ES quantity was associated with maximal body mass index (BMI) reached pre-MBS (r = .48, p < .05) and current BMI (r = .35, p < .05). Greater ES inconvenience was associated with higher social physique anxiety and age (R2 = .50, p < .01). Qualitative data were summarized into 4 themes: psychosocial experiences living with ES, physical ailments due to ES, essential support and unmet needs, and beliefs of ES quantity causes.

CONCLUSION

Measured ES quantity is related to higher BMI, but not reported inconveniences. Greater self-reported ES quantity and inconveniences were associated with body image concerns.

The Impact of Abdominal Body Contouring Surgery on Physical Function After Massive Weight Loss: A Pilot Prospective Matched Comparison

BACKGROUND

Many individuals develop excess skin (ES) following massive weight loss (MWL). Patient-reported outcomes demonstrate that abdominal ES negatively impacts perceived physical function which is improved by abdominal body contouring surgery (ABCS). However, the effect of ABCS on objective measures of physical function is unknown.

OBJECTIVES

The aim of this study was to examine the impact of ABCS on objective measures of physical function in individuals who have undergone MWL.

METHODS

Patients who have undergone MWL with abdominal ES (grade, ≥2) underwent the following physical function assessments: 9-item modified physical performance test (mPPT), chair stand, star excursion balance test (SEBT), timed up and go (TUG), modified agility T test, and 6-minute walk test (6-MWT). Perception of physical exertion and BODY-Q questionnaire scales were also collected. Nonsurgical controls (n = 21) and those who had undergone ABCS (n = 6) after the first visit performed a second physical function assessment 8 to 12 weeks later to allow for postoperative healing.

RESULTS

No ceiling or floor effect was detected for any physical function measure. The intraclass correlation coefficient was 0.78 (95% CI, 0.44, 0.91) for the mPPT and >0.80 for all other measures. The effect sizes were 0.74 (75% CI, 0.19, 1.28) for the mPPT, 0.54 (75% CI, 0.00, 1.08) for the SEBT, -0.63 (75% CI, -1.17, -0.09) for the modified agility T test, and 0.79 (75% CI, 0.24, 0.13) for the 6-MWT.

CONCLUSIONS

The mPPT and tests involving dynamic balance, agility, and walking were reliable and showed medium to large effect sizes, suggesting that these tests may be sensitive to change following ABCS.

LEVEL OF EVIDENCE: 2

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.

The Use of Validated Visual Scales in Plastic Surgery: Where Are We Now?

BACKGROUND

The assessment of the human body, whether for aesthetic or reconstructive purposes, is an inherently visual endeavor. Ideally, reproducible, prompt, and cost-effective systems of visual evaluation would exist that can provide validated assessments of the aesthetic endpoints of treatment. One method to accomplish a standardization of the appreciation of visual endpoints is the use of visual scales. The goal of this systematic review is to summarize and evaluate the use of validated visual scales within aesthetic medicine, dermatology, and plastic and reconstructive surgery.

METHODS

A literature search was performed with a defined search strategy and extensive manual screening process. The Medical Outcomes Trust guidelines for visual scales in medicine were used, with special attention paid to each study's validation metrics. The review process identified 44 publications with validation data of sufficient quality from an initial survey of 27,745 articles. All rating scales based on imaging other than standardized clinical photographs were excluded.

RESULTS

The review demonstrates that validated visual assessment in plastic surgery is incomplete. Within specific subfields of aesthetic medicine and dermatology, many of the ( n = 20) facial aging scales were well-validated and demonstrated high reliability. Publications ( n = 8) focused on the evaluation of facial clefts demonstrated heterogeneity in the methods of validation and in overall reliability. Within the areas of breast surgery ( n = 9), body contouring ( n = 2), and scarring ( n = 5), the scales were variable in the methods used and the validation procedures were diverse. Scales using a visual guide tended to have better interrater (kappa = 0.75) and intrarater reliability (kappa = 0.78), regardless of the specific area of interest.

CONCLUSIONS

The fields of aesthetic medicine, and aesthetic and reconstructive plastic surgery require assessment of visual states over time and between many observers. For these reasons, the development of validated and reliable methods of visual assessment are critical. Until recently, the use of these tools has been limited by their time-consuming nature and cost.

A systematic review of body contouring surgery in post-bariatric patients to determine its prevalence, effects on quality of life, desire, and barriers

Many post-bariatric patients have impaired health-related quality of life (HRQoL) due to excess skin following weight loss; however, it is inconclusive whether body contouring surgery (BCS) improves this impairment. We aimed to comprehensively summarize existing evidence of the effect of BCS on the HRQoL (primary outcome) and determine the prevalence of, the desire for, and barriers to BCS (secondary outcomes). Randomized controlled trials, cohort, cross-sectional, case-control, and longitudinal studies were systematically searched in PubMed, Embase, the Cochrane Central, and Web of Science. After screening 1923 potential records, 24 studies (representing 6867 participants) were deemed eligible. Only 18.5% of respondents from cross-sectional studies underwent BCS, with abdominal BCS as the most common procedure. Most participants desired BCS but listed "cost" and "lacking reimbursement" as the main barriers. Results suggest that most post-bariatric patients who underwent BCS experienced improvements in their HRQoL, which could be seen in almost every dimension evaluated, including body image and physical and psychosocial functions. Therefore, both bariatric and plastic surgeons should regard BCS not only as an aesthetic supplement but also as a vital part of functional recovery in the surgery-mediated weight loss journey and, thus, provide it to more post-bariatric patients.

The PRS Rainbow Classification for Assessing Postbariatric Contour Deformities

Supplemental Digital Content is available in the text.

Background:

There is a need for a reliable classification system to grade contour deformities and to inform reimbursement of body contouring surgery after massive weight loss. We developed the PRS Rainbow Classification, which uses select photographs to provide standardized references for evaluating patient photographs, to classify contour deformities in postbariatric patients. To assess the reliability of the PRS Rainbow Classification to classify contour deformities in massive weight loss patients.

Methods:

Ten independent experienced plastic surgeons, 7 experienced medical advisors of the healthcare insurance company, and 10 laypersons evaluated 50 photographs per anatomical region (arms, breast, abdomen, and medial thighs). Each participant rated the patient photographs on a scale of 1–3 in an online survey. The inter-observer and the intra-observer reliabilities were determined using intra-class correlation coefficients (ICCs). The ICC analyses were performed for each anatomical region.

Results:

Inter-observer reliability was moderate to good in the body regions “arms,” “abdomen,” “medial thighs,” with mean ICC values of 0.678 [95% confidence interval (CI), 0.591–0.768], 0.685 (95% CI, 0.599–0.773), and 0.658 (95% CI, 0.569–0.751), respectively. Inter-observer reliability was comparable within the 3 different professional groups. Intra-observer reliability (test–retest reliability) was moderate to good, with a mean overall ICC value of 0.723 (95% CI, 0.572–0.874) for all groups and all 4 body regions.

Conclusions:

The moderate to good reliability found in this study validates the use of the PRS Rainbow Classification as a reproducible and reliable classification system to assess contour deformities after massive weight loss. It holds promise as a key part of instruments to classify body contour deformities and to assess reimbursement of body contouring surgery.

Abdominoplasty in Hemodialysis Patients Before Transplant

Morbid obesity in patients with chronic kidney disease is a contraindication for inclusion on the kidney transplant waitlist.Despite intentional weightloss,the persistence of the abdominal adipose panniculus poses postoperative risks, such as infection of the surgical site and seromas. We describe 2 cases of patients on hemodialysis who had a body mass index greater than 35 kg/m² who underwent abdominoplasty before transplant without perioperative complications. One patient received a living-related kidney transplant (donor was the brother) without complications.

Body Contouring Surgery after Massive Weight Loss: Excess Skin, Body Satisfaction, and Qualification for Reimbursement in a Dutch Post-Bariatric Surgery Population

BACKGROUND

Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post-bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post-bariatric surgery population.

METHODS

Post-bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body.

RESULTS

A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the "desire" population; 44.1 percent of these patients met the weight criteria.

CONCLUSIONS

Post-bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.

The Danish Scale for visual rating of massive weight loss body contours. Conceptualization and construct

The 'Danish Scale' (DS) is a visual rating scale of massive weight loss body contour deformities and excessive skin in female MWL-patients with current BMI < 30 kg/m² and massive weight loss defined as BMI loss (delta-BMI) > 15 kg/m², regardless of weight loss method. The scope of the scale is to simplify the reporting of objective findings by a three-step grading of minor, moderate and severe body contour changes in six different body regions: breasts, abdomen, upper back, buttocks, arms and legs. The DS is presented with descriptions of the conceptualization and construct of the scale. It provides a new visual reference tool for indications and preoperative planning in MWL body contouring, that is specific for the post-MWL BMI-range between 21 and 30 kg/m² and, at the same time, simpler than previous scales. The scale combines evaluations of different and adjacent body regions in a simple manner and presents modern cut-off points for health insurance reimbursement for MWL body contouring as offered in the Danish public health care system. The DS was developed by repeat expert discussions until final nationwide consensus was reached and can act as an adjunct to the written guidelines by the National Board of Health in Denmark.

What Is Known About the Correlates and Impact of Excess Skin After Bariatric Surgery: a Scoping Review

Although bariatric surgery (BS) improves health among adults with severe obesity, it results in excess skin in more than 70% of adults. The purpose of this study was to synthesize current knowledge on (1) the impact of excess skin experienced by adults after BS and (2) the correlates of excess skin quantity and inconveniences. PubMed, PsyArticles, and CINAHL databases were searched in May 2016 for relevant studies. Titles, abstracts, and full texts of studies retrieved were screened independently by two reviewers against inclusion criteria: (1) peer-reviewed primary research studies, (2) samples with adults who underwent BS, and (3) studies reporting the impact of excess skin and/or excess skin correlates. Thirteen quantitative and eleven qualitative studies met inclusion criteria. Negative physical, psychosocial, and daily life impacts of excess skin were reported in 67, 75, and 83% of studies, respectively. Women reported more excess skin and greater inconveniences of excess skin than did men. Based on the quantitative studies, pre-BS BMI, time since BS, and type of BS were not significantly associated with inconveniences of excess skin; findings were inconclusive for other correlates found (e.g. age, weight loss, BMI). Excess skin may adversely impact adults' physical and psychosocial functioning, as well as their activities of daily life after BS. However, evidence is lacking to determine which adults may be at heightened risk of developing or being negatively impacted by excess skin. More research on correlates of excess skill is needed to inform the development of tailored interventions in those more vulnerable to developing excess skin after BS to mitigate adverse consequences.

Absence of an Additional Metabolic Effect of Body Contour Surgery in Patients With Massive Weight Loss After Laparoscopic Roux-En-Y Gastric Bypass

INTRODUCTION

Body contour surgery (BCS) is a combination of soft tissue resections that have proven to be an effective treatment for the aesthetic and functional problems related to massive weight loss (MWL). There are no studies analyzing the metabolic effect of large volume adipose tissue flap resection in patients with MWL after bariatric surgery.

METHODS

This study was a retrospective review of adults who underwent BCS after gastric bypass. Preoperative clinical and laboratory data were compared with 1- and 2-year postoperative follow-up.

RESULTS

A total of 62 patients with a mean age of 41 years were analyzed. Seventy-nine percent of them were women. Most procedures included abdominal flap resection alone or in combination with other areas. Mean resected tissue weight was 6.2 kg. We found that weight and body mass index (BMI) were lower 1 year after BCS (P < 0.05), but this was not maintained after 2 years. There were no differences for systolic or diastolic blood pressure, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, or fasting glucose after 1 and 2 years of the BCS. A subgroup analysis showed that the transient weight and BMI improvement was only apparent 1 year after BCS in those patients with flap resections more than 8 kg.

CONCLUSIONS

There are no differences in blood pressure, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, or fasting glucose 1 and 2 years after BCS in patients who experienced MWL after gastric bypass. Although weight and BMI were transiently lower in those patients with tissue flap resections more than 8 kg, this effect disappeared after 2 years.