Patient Characteristics and Spending Among Individuals Undergoing Ambulatory Panniculectomy and Abdominoplasty in the US from 2016 to 2019

BACKGROUND

Abdominal contouring surgery can provide both functional and cosmetic benefits to patients with abdominal soft tissue laxity. Although these procedures have been studied in the inpatient setting, few studies describe abdominal contouring surgery in the ambulatory setting.

OBJECTIVE

The purpose of this analysis was to investigate patterns in patient demographics between functional panniculectomy and cosmetic abdominoplasty using national data from the last four years.

METHODS

Using the Nationwide Ambulatory Surgery Sample, we analyzed outpatient abdominal contouring procedures between 2016 and 2019. Encounters with a CPT 15830 were included. Procedures with ICD Z41.1 or CPT 15847 modifiers were defined as cases of cosmetic abdominoplasty.

RESULTS

A weighted estimate of 95,289 encounters were included, with 66,531 (69.8%) functional panniculectomy and 28,758 (30.2%) cosmetic abdominoplasty procedures. Among patients with a history of bariatric surgery (23.8%; 95% CI, 22.3-25.4%), there was a 28.5% (4,866 in 2016 vs 6,254 in 2019) increase in panniculectomy and abdominoplasty. Compared with individuals who underwent cosmetic abdominoplasty, individuals who underwent functional panniculectomy were more racially diverse, had more comorbidities, and were more likely to be from low-income backgrounds.

CONCLUSIONS

Rates of abdominal contouring surgery in the ambulatory setting have increased in recent years especially among individuals with previous bariatric surgery. There are important demographic and clinical differences between patients who underwent functional panniculectomy and cosmetic abdominoplasty including primary payer, comorbidities, and racial identity.

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 .

Comparison of Histological Skin Changes After Massive Weight Loss in Post-bariatric and Non-bariatric Patients

BACKGROUND

Changes in the skin structure, including the collagen and elastin content, have been reported with massive weight loss (MWL) following bariatric metabolic surgery (BMS) and have been correlated to a higher risk of complications after body-contouring surgery (BCS). This study aimed at comparing the histological characteristics of the skin of patients having surgical MWL (SMWL) post-BMS to those with non-surgical massive weight loss (NSMWL).

METHODS

This prospective study compared the epidermal thickness, and collagen and elastin fibers content in 80 skin biopsies obtained from BCS procedures performed to patients who experienced MWL defined more than 50% of excess weight loss (%EWL) either SMWL (40 biopsies) or NSMWL (40 biopsies). Twenty biopsies in each group were obtained from abdominoplasties and 20 from breast reductions. Epidermal thickness was measured in H&E-stained sections, collagen fibers were assessed using Masson trichrome-stained sections, and elastin fibers were assessed using Modified Verhoeff's stained sections. Image analysis software was used to calculate the fractions of collagen and elastin fibers.

RESULTS

This study included 77 patients, 38 SMWL patients, and 39 NSMWL patients. The SMWL group had a significantly higher age (p < 0.001), a longer time interval from intervention (p < 0.001), higher initial weight (p < 0.001), higher initial BMI (p < 0.001), lower current weight (p = 0.005), lower current BMI (p < 0.001), and significantly higher %EWL than NSMWL group (p < 0.001). No significant differences were detected between the two groups regarding complications after abdominoplasty (p = 1.000). The elastic fibers content in the dermis was significantly higher in the abdominal region of the NSMWL group than SMWL (p = 0.029). All other parameters showed non-significant differences between NSMWL and SMWL in the skin of abdomen and breast.

CONCLUSION

The SMWL group had a significant reduction in elastic fiber content in the skin of the abdomen compared to the NSMWL group. The collagen content was equally reduced in both groups with non-significant differences in both breast and abdomen regions in both groups.

The financial toxicity of postbariatric body contouring surgery: a survey study of an urban tertiary care center's patients

BACKGROUND

Patients with obesity who undergo bariatric surgery achieve sustained weight loss but are often left with excess skin folds that cause functional and psychological deficits. To remove excess skin, patients can undergo postbariatric BCS; however, cost and lack of insurance coverage present a significant barrier for many patients.

OBJECTIVES

This study aimed to characterize the financial impact of treatment on all patients who received bariatric surgery and to compare between those receiving only bariatric surgery and those with postbariatric BCS.

SETTING

Email-based survey study at an urban tertiary care center.

METHODS

Surveys that included the COST-FACIT were sent to patients with a history of bariatric surgery and/or post-bariatric BCS.

RESULTS

One hundred and five respondents completed the survey, of which 19 reported having postbariatric BCS. Patients with postbariatric BCS had slightly higher COST scores than those receiving bariatric surgery only, but this difference was not significant (15.6 versus 17.8, P = .23). Most patients (76%) did not have an awareness of BCS or BCS cost prior to bariatric surgery, and many (68%) had more loose skin than anticipated.

CONCLUSIONS

Financial toxicity was similar across all postbariatric surgery patients surveyed regardless of history of BCS. However, survey respondents noted a gap between patient education and expectations around loose skin and body contouring that can be addressed through improved presurgical counseling.

Interplay of Oblique Flankplasty with Vertical Medial Thighplasty

After 25 years' experience, the authors present the senior author's current integration of lower body lift with vertical medial thighplasty. Mostly, oblique flankplasty with lipoabdominoplasty (OFLA) has replaced the traditional transverse posterior lower body lift and abdominoplasty due to improved esthetics and lower rate of complications. OFLA proceeds either immediately or as a first stage to the medially based reduction of thighs. L-vertical medial thighplasty, facilitated by excision site liposuction and scalpel assisted skin avulsion, is our preferred complimentary operation for predictable results and low rate of complications.

Patient Evaluation and Surgical Staging

The present article discusses the evaluation and surgical planning of body contouring procedures for weight loss patients. These patients require thorough preoperative evaluation and patient education. Distinction should be made between massive weight loss and moderate medication-assisted weight loss (MMA) as these patient populations are managed differently and there are unique preoperative considerations with the MMA population. Given that weight loss patients often have multiple concerns, combination procedures are often utilized and must be planned with the patient's goals and safety in mind.

Litigation Cases After Post-Bariatric Surgery: Lesson from the Past

BACKGROUND

Due to the high demand of post-bariatric surgeries, the number of litigation cases is rapidly growing. Even if surgical mistakes still represent one of the main causes of medico-legal issues, many disputes depend on what happens in the post-operative course. In this article we analyzed the litigation cases that occurred in our Plastic Surgery Department, the current literature about medico-legal disputes and the importance of the doctor-patient relationship.

PATIENTS AND METHODS

The medical records of 788 post-bariatric surgeries, the post-operative complications and the related litigation cases from January 2015 to December 2019 were collected, analyzed and compared.

RESULTS

We performed 380 abdominoplasties, 28 torsoplasties, 65 breast reductions, 99 mastopexies, 94 brachioplasties, 52 thighplasties, 65 liposuctions and 5 facelifts between 2015 and 2019. Eight patients complained of medical issues and claimed for litigation. Despite in all cases the judges highlighted the risk of consent misinterpretation, the payout was granted only in one case.

CONCLUSION

Post-bariatric patients often mistake their preoperative condition and consider body contouring procedures as an aesthetic surgery treatment. Patients should be therefore clearly informed about the complexity of body contouring procedures after massive weight loss, which should never be compared to aesthetic surgery. Surgeons should always promote the communication with their patients and build a strong and trustworthy relationship. This attitude will allow to deal more easily with complications and, in the worst situations, with medico-legal litigations.

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 .

[Treatment of pseudogynecomastia in massive weight loss patients: Liposuction assisted and made-to-measure desepidermization technique]

BACKGROUND

After massive weight loss (MWL), the chest in men may show significant deformities. The surgical treatment of gynecomastia after MWL remains a difficult and partially misunderstood surgery due to 4 main factors: a complex excess of skin in height and width that sometimes continues in the axilla or dorsal region, a predominantly fatty rather than glandular component, the malposition of the nipple-areola complex (NAC) that is often enlarged and an inframammary fold (IMF) that is often marked. The techniques currently described are either insufficient or lead to frequent and/or significant complications. The authors describe a new approach that dissociates the treatment of the volume and the skin with a customized resection that is simple, reproducible and safe. Our goal is to improve patient satisfaction while reducing complication rates.

METHODS

Seventeen patients with adipomastia with excess skin after massive weight loss were operated on using liposuction and skin redraping technique. The authors describe the technique, indications and contraindications of the procedure and analyze the results.

RESULTS

The average age of the patients was 39 years. The average body mass index (BMI) before weight loss is 42,7kg/m², the average weight loss before body correction is 49kg, with an average delta of BMI loss of 15,34kg/m^2. The average stay in hospital is 1,3 nights. No patient had major complications (hematoma, hemorrhage, necrosis, thrombophlebitis, immediate surgical revision to treat complications). Minor complications including scar dehiscence, infection, steatonecrosis, and distant scar correction were reported in 2 patients, i.e. 11%.

CONCLUSION

Liposuction assisted and desepidermization torsoplasty is a new technique for correction of pseudogynecomastia in MWL patients. The results are reproductible and the complication rates are low. There is no dead space and therefore no drains are needed. There is little pain and a short hospital stay. This technique is simple, quick and easy to learn. However, it is only applicable in adipomastia. A different technique should be used in the presence of firm glandular tissue.

[Complications and quality of life after bodylift: About 143 patients]

INTRODUCTION

The rise of bariatric surgery has led to a considerable increase in the demand for weight loss surgery. The lower body lift consists of removing the residual abdominal fat and skin excess and re-tensioning the surfaces. The objective of our study was to evaluate the associated complications, as well as the consequences of this surgery on the quality of life of the patients.

MATERIALS AND METHODS

A retrospective monocentric study was conducted in patients operated on for lower body lift between 2010 and 2019 at the University Hospital of Besançon. We collected postoperative complications and studied the satisfaction and quality of life of the operated patients using the Body-QoL and SF-36 questionnaires.

RESULTS

One hundred forty-three patients were included with a mean age of 41.2 years. The mean body mass index was 26.6kg/m² with a mean weight of 73.8kg and a mean weight loss of 54.4kg. Forty-one patients (29.7%) had at least one complication. Most complications were minor, with 16.8% of scar disunions, and 7% of complications were major, requiring revision surgery. Ninety-three patients (65%) responded to the satisfaction questionnaires with improvement mostly in physical symptoms and social life.

CONCLUSION

The lower body lift is an effective, safe procedure with mostly minor complications that do not influence quality of life. Patient satisfaction is high, and it is therefore justified to continue offering this procedure to correct the sequelae of massive weight loss.

The Three-Hour Lower Body Lift: Evolution of a Technique and Personal Experience after 155 Consecutive Cases

BACKGROUND

Body-contouring is a surgical field in growing demand, as the number of massive weight loss patients following bariatric surgery is increasing. The purpose of this study was to provide a straightforward and time-efficient circumferential body lift technique to achieve optimal lower truncal contouring.

PATIENTS AND METHODS

A total of 155 massive weight loss patients (133 women and 22 men) underwent lower body lift surgery between 2006 and 2018. The mean preoperative weight reduction and body mass indices were 56.5 ± 16.6 kg and 26.7 ± 4.7 kg/m2, respectively. The preoperative markings focused on the back and gluteal region, and the modified surgical technique are described. Additionally, improvements of intra-operative repositioning of the patient and how to deal with sterilization and dressings are elucidated.

RESULTS

The average intra-operative time was 178 ± 54.6 minutes. The mean follow-up of all patients was 8.2 ± 2.4 years. The most common complications were related to wound dehiscence (n = 38) and seroma (n = 18). The mean weight of the resected tissue was 3 056 ± 1 816.5 g.

CONCLUSION

The lower body lift represents an effective and safe body contouring procedure to treat massive weight loss patients with multiple regions of concern. The current study describes a modified surgical technique that reduces operating time and complications, notably.

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 http://www.springer.com/00266 .

"The use of Autologous Flaps in Breast Reshaping After Massive Weight Loss: A Systematic Review"

BACKGROUND

Massive weight loss (MWL) has a positive impact on the comorbidities associated with obesity but leaves patients with ongoing body issues due to skin excess. Almost all patients present some degree of breast ptosis and breast volume deficiency, which can be addressed with different techniques including autologous flaps.

MATERIAL AND METHODS

A literature search was conducted by using PubMed, Google Scholar, and Cochrane databases. Patient's characteristics, type of bariatric surgery, amount of weight loss, flap size and design, simultaneous breast and extra-breast procedures were analyzed. Aesthetic and patient-reported outcomes, postoperative complications, revision rate, and donor site morbidity were also registered.

RESULTS

Twelve articles fulfilled inclusion criteria, and 79 patients were included, for a total of 157 flaps. Different flap designs and flap combinations were described; those originating from lateral chest wall area were the most commonly used. Simultaneous breast procedures were reported in 72 patients. Simultaneous extra-breast body contouring (BC) procedure was performed in 40 cases. The overall complication rate was 9.55% and a total of ten revisionary procedures were performed. Satisfaction of the patients was globally quite high.

CONCLUSIONS

Advantages of the use of autologous tissue in breast reshaping after MWL is the avoidance of implant-related complications and the simultaneous improvement of the silhouette. The complication rate resulted in acceptable, aesthetic, and patient-reported outcomes resulted to be encouraging, even if there was a lack of standardization in the evaluation. A comparative randomized study to confront the use of autologous flaps combined with mastopexy versus the use of implants combined with mastopexy can be useful to confirm the promising results.

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 .

Lipobrachiopexy: Cosmetic Outcomes and Limb Lymphatic Function of a Novel Brachioplasty Technique in Massive Weight Loss Patients

BACKGROUND

Many types of brachioplasty techniques have been described in the literature, and the main focus has been scar aesthetics, reproducibility and safety. Little attention has been given to other two aspects of the procedure: overall aesthetic with a focus on the torso-brachial angle and on the lymphatic distress related to the procedure. In this paper, we described a novel technique of brachioplasty called lipobrachiopexy, a lymph-sparing procedure which includes tendon suspension suture to improve cosmetics .

PATIENTS AND METHODS

Over 18 months, 22 consecutive patients underwent bilateral lipobrachioplasty with circumferential liposuction sparing brachial artery perforators, J-scar dermolipectomy and superficial fascia suspension to the pectoralis major tendon. Aesthetic outcomes, lymphatic function, sensory function and patient's satisfaction were evaluated at 1-year follow-up. The correction of the bat wing deformity and the shape of the transition of the upper arm to the chest was evaluated by quantifying the torso-brachial angle using Photoshop. Lymphatic function was analysed pre-operatively at 1, 6 and 12 months after surgery by indocyanine green lymphography (PDE, Hamamatsu Photonics, Japan).

RESULTS

An average of 447.5 cc (range, 350-550 cc) of fat was aspirated for each side. No major complications were experienced. Patients' and surgeons' satisfaction was high to very high in all cases. The lymphatic function was found preserved, with the same physiological linear patterns and tracer progression pre-operatively and 1 year after surgery. The torso-brachial angles showed significant improvements (86.7 ± 14.7-100.7 ± 10.2 right side and 85.4 ± 16.3-101.5 ± 9.9 left side).

CONCLUSION

Lipobrachiopexy is a safe and effective technique that adds to the recent trends in brachioplasty, a reestablishment of the brachial fascial systems and addressing the anatomical etiological factor of the bat wing deformity.

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 .

Medial Thighplasty Improves Patient's Quality of Life After Massive Weight Loss: a Prospective Multicentric Study

BACKGROUND

The aim of this study was to assess the impact of medial thighplasty following massive weight loss on the quality of life of patients and on their sexual life.

METHODS

We performed a multicentric, prospective study on the quality of life after massive weight loss using the Short-Form 36 questionnaire, the Female Sexual Function Index questionnaire, and the Moorehead-Ardelt Quality of life questionnaire. Forty-nine patients who underwent medial thighplasty were included in three centers and evaluation was made pre- and post-operatively.

RESULTS

The mean age of the patients was 44 ± 12.5 years. The average pre-medial thighplasty body mass index was 27 ± 3.8 kg/m2. All the categories of the SF36 questionnaire scored higher after surgery apart from "health change" but only the "role limitations due to emotional problems" category was significantly improved (p = 0.0081). Similarly, the Moorehead-Ardelt questionnaire showed a positive impact of the surgery on the quality of life in general (mean total score 1.04 ± 1.37) and on self-esteem, physical activity, social relationships, and work performance. Interestingly, sexual activity was not improved by the surgery and this result is in line with the FSFI, which showed no effect of medial thighplasty on sexual life.

CONCLUSIONS

Medial thighplasty improves the quality of life of patients after massive weight loss but does not seem to modify the sexual quality of life. These results clearly indicate that this surgery should be widely offered to patients seeking reconstruction of massive weight sequelae.

A Comparative Analysis of Fleur-de-Lis and Traditional Panniculectomy after Bariatric Surgery

INTRODUCTION

The Fleur-de-Lis panniculectomy (FdL) adds a vertical component to correct complex contour deformities after massive weight loss by addressing supra-umbilical horizontal skin excess which is not addressed with infra-umbilical transverse panniculectomy (TP). We aim to perform a head-to-head comparison of clinical outcomes and patient reported outcomes (PROs) between FdL and TP.

METHODS

A retrospective review of patients ≥18 with a history of bariatric surgery undergoing FdL or TP by a single plastic surgeon between 07/01/2015 and 05/31/2020 was conducted. Surgical site occurrences (SSOs) including surgical site infection (SSI), delayed healing, cellulitis, seroma, hematoma, surgical site occurrences requiring procedural intervention (SSOpi), and a composite of other postoperative outcomes were assessed. In addition, patient satisfaction was analyzed using the Body-Q questionnaire across 12 domains.

RESULTS

The analysis included 56 patients; 26 and 30 patients who were treated with FdL and TP, respectively. Cohorts were statistically similar in terms of age, gender, BMI, and co-morbid conditions. The overall complication rate was 50% (FdL n = 14 (53.9%), TP n = 14 (46.7%); p = 0.592). On multivariate analysis, pannus weight was associated with the development of SSO (p = 0.04). FdL incision, however, was not an independent risk factor for adverse outcomes. Absolute improvement in PROs was similar in both cohorts across multiple domains.

CONCLUSION

FdL showed a comparable safety and efficacy profile to TP when performed in post-bariatric surgery patients, with equivalent improvement in PROs across multiple domains. Preoperative weight loss should be encouraged in this population as pannus weight is an independent risk factor for complications.

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 .

Lipo-Bodylift Reconstruction Following Massive Weight Loss: Our Experience with 100 Consecutive Cases

BACKGROUND

We report our experience using the Lipo-Bodylift technique for circumferential lower trunk reconstruction following massive weight loss.

METHODS

The procedure combines extensive circular liposuction with circular skin resection immediately under the dermis. We classify lower trunk deformities using three parameters: (1) excess skin (in the horizontal direction, or both horizontally and vertically); (2) the body mass index (BMI); and, (3) skin quality (hyperlaxity or a normal tone). All patients can be divided into four groups, of whom groups I and II are the best candidates for the Lipo-Bodylift procedure. We also describe our perioperative management and patient outcomes, with a focus on postoperative complications.

RESULTS

Between January 2015 and January 2020, 100 patients underwent Lipo-Bodylift treatment. The median patient age was 41 years. The median preoperative BMI was 26.3 kg/m². The median drainage duration and hospital stay were both 3 days. Of all patients, 30% experienced at least one complication, 2% of which were major. Of the minor complications, 27 patients evidenced wound dehiscence. Only (positive) smoking status was significantly associated with postoperative complications (p < 0.001).

CONCLUSION

We developed the Lipo-Bodylift technique after analyzing changes in the skin and subcutaneous fat after massive weight loss. The technique completes the arsenal of body contouring techniques, appears to be less invasive than the undermining that is usually performed during circumferential reconstruction of the lower trunk, and is associated with a lower rate of major complications.

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.

The Dual Vascular Pedicle: A Novel Method to Approach Challenging Cases in Single-Stage Mastopexy/Augmentation

BACKGROUND

Age, pregnancy and weight change can affect the shape of the female breast. Various mastopexy/augmentation techniques have been described to address these changes which work well in primary and uncomplicated cases. However, there is a distinctive category of high-risk patients which includes post-bariatric, active smokers, those with poor skin quality, wanting larger implants or undergoing secondary surgery. The complications reported in this group of patients are as high as 32%.

MATERIALS AND METHODS

We describe a new technique of one-stage mastopexy/augmentation, using a wide dermo-glandular pedicle, and our early results with 51 consecutive patients.

RESULTS

Fifty-one patients were operated between January 2016 and September 2018, with a mean age of 40.0 years. Ten patients were smokers, eight were post-massive weight loss, six had previous mastopexy. At a mean follow-up of 22 months, only two patients had a unilateral bottoming out. There were no incidents of hematoma, seroma, capsular contracture or major tissue-related complications.

CONCLUSION

Plastic surgery has been described as a struggle between beauty and blood supply. We have performed a one-stage mastopexy/augmentation using a wide and thick dermo-glandular glandular pedicle to maximize the blood supply in a range of challenging patients with promising results.

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 .

Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation: Applications for oncoplastic and massive weight loss surgery

Background

Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation provides the benefits of addressing axillary tissue excess and avoiding intramuscular dissection. Previous experience with the LICAP flap in patients with prior breast conservation therapy (BCT) has led to the development of an extended version for massive weight loss (MWL) patients as well.

Methods

A retrospective review of all cases of LICAP flaps was performed by a single surgeon. Data were subsequently extracted and analyzed including patient demographics, indication and timing of volume augmentation, complications, and follow-up length.

Results

From 2016 to 2020, 12 patients underwent 16 LICAP flaps for volume augmentation. Indications for volume augmentation included deficits from prior oncologic surgery (ten patients) and loss of volume due to MWL (two patients). The average BMI was 29.9 kg/m². Among the oncologic group, eight patients had delayed reconstruction, while two were immediate. Nine patients underwent radiation prior to volume augmentation. Eight of the 14 patients simultaneously received fat grafting. There were 4 cases of delayed wound healing that improved with local wound care. There were no statistically significant differences in complication rates between the oncologic and MWL groups. The average length of follow-up was 11.4 months.

Conclusions

This study supports that the application of the LICAP flap can be effectively broadened from the oncologic population to the MWL population. If needed, extending the flap provides an option to simultaneously address excess axillary and back tissue.

Trunkoplasty after massive weight loss - a case series with a one-stage body contouring procedure for the NHS patient

Body contouring post massive weight loss (MWL) is a considerable task and is often a functional rather than esthetic operation. Clinicians are often encouraged to solve multiple issues in a single setting that can be difficult in the MWL patient. A simple abdominoplasty often does not provide a satisfactory outcome in such patients and may result in disharmony of the esthetic unit of the trunk. Trunkoplasty is a technique that combines a fleur-de-lis abdominoplasty and reverse abdominoplasty. This is a one-stage operation to address the extra skin of the whole trunk esthetic unit. The average operation time was 4 h with a 3-surgeon team. No blood transfusions were required. There were 3 out of 15 patients with wound-related problems and no incidence of postoperative hematomas. There were no returns to theaters. Seromas formed were not symptomatic and no interventions were required. The average inpatient stay was 6.9 days and a return to work after 4 weeks. It can improve abdominal contour, define the waist, and improve mons ptosis in one stage without any change in position. This procedure has some specific advantages (accommodates preexisting abdominal scars), but also has shortcomings as compared to "standard" circumferential body contouring.

Mastopexy with Autologous Augmentation in Women After Massive Weight Loss: A Randomized Clinical Trial

BACKGROUND

Breast reshaping or mastopexy following massive weight loss can be challenging. The LOPOSAM (lower pole subglandular advancement mastoplasty) technique has shown promising results for correction of ptotic, wide, lateralized and deflated breasts following massive weight loss.

MATERIALS AND METHODS

We compared the LOPOSAM technique to the mastopexy technique after massive weight loss described by Rubin JP, in a randomized trial. The main outcome measure was the total operative time. Secondary outcomes measures were socio-economic factors; length of hospital stay, numbers of sutures used, secondary corrective procedures, post-operative sick leave and surgeon- and patient-reported appearance of the breasts.

RESULTS

We included 22 women: 11 operated on by the LOPOSAM technique and 11 by the technique described by Rubin JP. The total operative time was 84.8 (SD 12.2) minutes in the LOPOSAM group and 99.1 (SD 23.5) in the Rubin JP group (p = 0.074). There were no differences related to days with drains, length of hospital stay or sick leave between the two groups. The surgeon- and the patient-reported appearance of the breasts changed significantly between the pre-operative and the 12-month post-operative assessments.

CONCLUSION

The LOPOSAM technique is a safe and quick surgical procedure for correction of ptotic, wide, lateralized and deflated breasts following massive weight loss and seems to provide results comparable to the better-known Rubin JP's technique. There was a trend that the LOPOSAM technique was faster to perform, however, not significant. The breast appearance improved significantly using both techniques when assessed by both surgeons and patients.

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 .

Body Contouring Surgery Improves Physical Activity in Patients After Massive Weight Loss-a Retrospective Study

BACKGROUND

The aim of the study was to compare physical activity (PA) in patients who had undergone massive weight loss (MWL), before and after body contouring procedures.

METHODS

All patients undergoing body contouring surgery after MWL between 2007 and 2017 with a minimum follow-up of 6 months after the last procedure were included in this retrospective study. Excluded were those with a body mass index > 35 kg/m² and those with comorbidities leading to impaired PA. Quality of life (QOL) was assessed using the Moorehead-Ardelt QOL Questionnaire II. Evaluation of PA was obtained with the International Physical Activity Questionnaire (IPAQ) short form and the Freiburg PA Questionnaire. Functional impairment during exercise was analyzed using a self-designed functional impairment score (FIS).

RESULTS

In the 45 patients completing the survey (37 female, 8 male), an improvement in QOL (p < 0.001) and PA scored by the IPAQ (p = 0.017) was found. The Freiburg PA Questionnaire showed no difference in PA before and after body contouring surgery (p = 0,274). Furthermore, scores of the FIS indicated a decrease of functional impairment during physical activity after body contouring surgery (p < 0.001).

CONCLUSION

Body contouring improves QOL and PA in patients after massive weight loss. The results of our study confirm the important role of plastic surgery in the treatment and maintenance of health of patients with former obesity.

Morphological changes of the human face after massive weight-loss due to bariatric surgery

The aim of this study was to evaluate the morphological changes in the face of obese patients during massive weight loss using a more reliable method than two dimensional photographs or tape measures. The faces of 23 patients were recorded prior to and six months after bariatric surgery. Distances between important anatomical landmarks of the face were calculated and the volume of the neck was compared. The distance between the Tragion and Subnasale (132.7 ± 6.804 mm to 131.5 ± 6.866 mm; p = 0.0003), and the distance between Tragion and Stomion became significantly longer 136.0 ± 8.016 mm to 134.3 ± 7.698 mm; p = 0.0031), while distances between the Tragion and Pogonion (150.2 ± 8.216 mm to 148.3 ± 8.383 mm; p < 0.0001), Tragion and Menton (152.3 ± 9.037 mm to 148.9 ± 9.623 mm; p < 0.0001), and Tragion and tip of the nose (144.9 ± 7.273 mm to 144.0 ± 7.416 mm; p = 0.0023) were significantly reduced. The mean volume loss of the neck was 75.218 ± 40.197 ml. No significant correlation was found between total weight loss and cervical volume loss (r = 0.3447; p = 0.1072). The morphological changes of the face after massive weight loss vary in different areas of the face. Patients and their attending physicians must be aware of the face's morphology change after massive weight loss in an extent that does not correlate with the total weight loss of the patient.

Abdominoplasty After Massive Weight Loss

After massive weight loss (MWL), patients present with deformities that are more severe and often different than those observed in standard cosmetic abdominoplasty. The first step is careful consideration of the special factors involved in preoperative screening of patients with MWL presenting for body contouring surgery. Once these patient factors are optimized and surgery is considered, careful analysis of anatomic deformities should ensue. Technical variations of standard abdominoplasty are often required. With proper attention to safe screening, analysis of the anatomic deformities, and application of relevant techniques, plastic surgeons can have a positive impact on the lives of these patients.

Impact of Lipo-Body Lift Compared to Classical Lower Body Lift on Postoperative Outcome and Patient's Satisfaction: A Retrospective Study

INTRODUCTION

Lately, the growing number of bariatric procedures performed each year led to an increasing demand for lower trunk reconstruction. Our team previously described the lipo-body lift (LBL) technique into lower duration of drainage and therefore seromas and other complications. In this study, we compared the classical body lift (CBL) technique to the LBL procedure.

MATERIALS AND METHODS

All patients who underwent a LBL or CBL after massive weight loss between November 2012 and October 2017 were included. Surgery outcome parameters were collected as well as patient satisfaction through a satisfaction score realized at least after 1 year postoperative. Comparisons between CBL and LBL were conducted to assess the surgery's safety and the patient's satisfaction.

RESULTS

A total of 130 patients were included, 61 patients who had a LBL were compared to 69 patients who had a CBL. The mean patient age was 39.64 ± 9.97 (21-66) years old, the mean body mass index before plastic surgery was 26.83 ± 3.08 kg/m² (19.83-32.69), and the average weight loss was 53.40 ± 17.37 kg. The two groups had comparable preoperative data. Duration of drainage and hospital stay was significantly lower in the LBL group than in the CBL (p < 0.0001 and p < 0.0001, respectively). Surgical outcomes were comparable between groups as well as patient satisfaction scores.

CONCLUSION

Lipo-body lift allows early discharge of the patient by reducing the duration of drainage without increasing the risk for complications. In our opinion, this technique should be used for type 1 and 2 patients with no contraindication for abdominal liposuction.

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.

Correction of High-Grade Pseudogynecomastia After Massive Weight Loss: Modified Inferior Dermoglandular Pedicled Transverse Scar Reduction

INTRODUCTION

Whereas body-contouring surgery after massive weight loss in women receives much attention, little attention has been devoted to accentuating the male physique. Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. The authors present their approach to high-grade pseudogynecomastia correction with preservation of the NAC on an inferior dermoglandular pedicle with transverse scar only closure and without any meaningful liposuction.

MATERIALS AND METHODS

A description of comprehensive pseudogynecomastia correction with the aforementioned technique followed by review of 58 consecutive patients operated on in our clinic from January 2017 to June 2018. Epidemiological data such as age, weight, height, body mass index (BMI), weight loss, and the medical history of each patient were collected. All patients were photo-documented preoperatively and postoperatively in a standard manner. During the operation, weight of resected tissue and operative time were noted.

RESULTS

Fifty-eight patients were operated on in a single stage. In our series, one patient had unilateral partial necrosis on nipple-areola complex, and two patients had minimal to moderate amounts of hematoma which were followed up without intervention. We did not encounter any infection-related complications or skin redundancy in our patients. Out of 58 patients, 55 of all the patients were highly satisfied with the aesthetic results. Three patients were mildly satisfied with the results, but they stress that moderate scar widening was the reason for the displeasure, not the definition of the chest which was deemed as satisfactory like the rest.

CONCLUSION

Our technique obviates the need for skin resection in a second operation, allows immediate skin recontouring, and provides a viable nipple-areola complex at the desired location. The patient does not have to suffer prolonged stress while awaiting skin retraction and is protected from a second dose of anesthesia and hospitalization.

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.

Lower Body Lift After Bariatric Surgery: 323 Consecutive Cases Over 10-Year Experience

BACKGROUND

Lower body lift is a widespread procedure for massive weight loss patients aimed to improve the contour of the lower trunk, gluteal region and proximal lower extremity. The data about complications are confusing, and there is a lack of uniform studies for massive weight loss patients. A simple formula to carry out a reliable procedure in a short time with a low complication rate should be advocated.

METHODS

This retrospective study analyzed data of 323 patients undergoing lower body lift after bariatric surgery over a 10-year period. Selection criteria, careful preoperative marking, reliable intra- and postoperative care and a few surgical tips are discussed. All the complications (both major and minor) and the aesthetic satisfaction were evaluated. Risk factors assessed were patient age, tobacco consumption, current BMI, operative time and combined surgery.

RESULTS

The overall complication rate was 42%. We recorded a lower rate of major complications and skin dehiscence; no infection and no skin necrosis were observed. The most frequent complication was seroma (35%). A complication development was straight related to age (p = 0.0177) and tobacco use (p = 0.0336). Patients' satisfaction about overall aesthetic was high.

CONCLUSIONS

We present our case load and describe an easy recipe to perform a safe surgery without undermining and liposuction in short operative times. The reasonable overall complication rate and the surprisingly lower rate of dehiscence and skin necrosis combined with a pleasant aesthetic result make the lower body lift an easy and safe procedure, when applied to the appropriate patient population.

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.

The BAPRAS screening tool for reimbursement in a postbariatric population

INTRODUCTION

Reimbursement of body-contouring surgery (BCS) is a worldwide problem: there is no objective instrument to decide which postbariatric patients should qualify for reimbursement. The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) has developed a screening tool for this purpose. In this study, we used a modified version of this screening tool in a postbariatric population and describe which patients would qualify for reimbursement using this tool.

METHODS

In this cross-sectional study postbariatric patients were asked to fill in an online questionnaire based on the BAPRAS screening tool with questions regarding complaints of overhanging skin and medical history. Weight loss data were extracted from a prospective database. The BODY-Q was added to assess patient-reported outcomes.

RESULTS

Patients who wanted to undergo BCS (n = 90) had higher screening tool scores and lower BODY-Q scores compared to patients who did not want BCS (n = 24). In total, 25 patients (26%) qualified for reimbursement, these patients had higher weight loss (33.5% versus 29.2%, p = 0.008), lower BMI (27.3 kg/m² versus 30.4 kg/m², p = 0.014) and more medical (4.0 versus 2.0, p = 0.004) and psychological complaints (88% versus 61%, p = 0.009). There was a significant, negative correlation between the screening tool scores and almost all BODY-Q scales.

CONCLUSIONS

Patients with a desire for BCS have more complaints of excess skin, which negatively impacts their well-being. With the modified BAPRAS screening tool, patients with the best weight (loss) and most medical and psychological complaints of excess skin qualified for referral and reimbursement of BCS.

The Impact of Massive Weight Loss on Psychological Comorbidities: A Large, Retrospective Database Review

BACKGROUND

The obese population has a higher incidence of mood disorders compared to individuals with normal body mass index (BMI). A better understanding of the unique psychosocial challenges faced by this patient population will allow physicians to better optimize patient psychosocial support systems perioperatively, as well as help the patient to maintain appropriate expectations.

METHODS

A large, retrospective database of 1135 patients with greater than 50 pounds of weight loss was reviewed. Data were analyzed using a multinomial regression model to determine the influence of psychosocial factors on the incidence of depression and anxiety.

RESULTS

Prior to massive weight loss, patients reported an overall incidence of depression and anxiety of 42.5% and 26.3%, respectively. Following massive weight loss, the incidence of depression decreased to 32.3% and the incidence of anxiety decreased to 22.0%. Patients with spousal support and with positive self-image were more likely to experience resolution of depression. Patients with positive self-image were likely to experience resolution of anxiety. Resolution of medical comorbidities correlated with a decrease in the rate of depression.

CONCLUSION

Depression and anxiety are prevalent in the massive weight loss patient population undergoing body contouring surgery. Support systems are a vital resource for patients with psychological comorbidities undergoing massive weight loss. Patients who have a positive self-image of themselves are more likely to experience resolution of psychological comorbidities. Physicians should consider recommending support groups and/or counseling in patients who have poor support and negative self-image.

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.

Deriving an overall appearance domain score by applying bifactor IRT analysis to the BODY-Q appearance scales

Purpose

With the BODY-Q, one can assess outcomes, such as satisfaction with appearance, in weight loss and body contouring patients using multiple scales. All scales can be used independently in any given combination or order. Currently, the BODY-Q cannot provide overall appearance scores across scales that measure a similar super-ordinate construct (i.e., overall appearance), which could improve the scales’ usefulness as a benchmarking tool and improve the comprehensibility of patient feedback. We explored the possibility of establishing overall appearance scores, by applying a bifactor model to the BODY-Q appearance scales.

Methods

In a bifactor model, questionnaire items load onto both a primary specific factors and a general factor, such as satisfaction with appearance. The international BODY-Q validation patient sample (n = 734) was used to fit a bifactor model to the appearance domain. Factor loadings, fit indices, and correlation between bifactor appearance domain and satisfaction with body scale were assessed.

Results

All items loaded on the general factor of their corresponding domain. In the appearance domain, all items demonstrated adequate item fit to the model. All scales had satisfactory fit to the bifactor model (RMSEA 0.045, CFI 0.969, and TLI 0.964). The correlation between the appearance domain summary scores and satisfaction with body scale scores was found to be 0.77.

Discussion

We successfully applied a bifactor model to BODY-Q data with good item and model fit indices. With this method, we were able to produce reliable overall appearance scores which may improve the interpretability of the BODY-Q while increasing flexibility.

Knowledge is power: Providing previsit insurance coverage information of body contouring procedures to improve understanding and satisfaction in the massive weight loss patient

INTRODUCTION

Because of the prevalence of obesity worldwide, the rates of bariatric surgery are increasing. Bariatric surgery is covered by insurance; however, often, a surgery to correct massive weight loss surgeries is not covered despite patient perception.

METHODS

One hundred patients were identified by their initial visit to the institutional Life After Weight Loss center. Fifty of them were randomized into receiving previsit educational materials about their individual insurance plans. All the patients were surveyed to assess whether this education improved their understanding and overall consultation experience.

RESULTS

Although a majority of patients believed "panniculectomy" would be covered by insurance, most subjects overestimated insurance coverage for other procedures. Nearly all respondents (93.8%) agreed that previsit educational material improved their understanding and the satisfaction of the visit.

CONCLUSION

Many patients believe body contouring procedures to be covered by insurance, although most are not. By providing patients with their individualized insurance plans, patients report improved understanding and overall satisfaction with the consultation.

Upper body lift and breast reshaping with lateral chest wall perforator propeller flap following massive weight loss

BACKGROUND

After massive weight loss (MWL), female patients often develop upper trunk laxity and severe breast deformities. Usually several procedures are required to address upper body contouring issues.

OBJECTIVES

To achieve better breasts and improve upper body contour, the authors employed a combined approach, associating lateral chest wall perforator propeller flaps with an upper bodylift (UBL).

METHODS

Between September 2015 and March 2017, nine post-bariatric patients underwent simultaneously an UBL and autologous augmentation breast reshaping with lateral chest wall perforator propeller flaps. The authors analyzed the clinical indications, results and complications of this procedure.

RESULTS

Eighteen lateral perforator propeller flaps for autologous breast augmentation-mastopexy associated with an UBL were performed successfully. Mean pre-MWL body mass index (BMI) was 54.3±10.9kg/m², with a mean preoperative pre-UBL BMI of 28.7±3.6kg/m². The average weight loss before surgery was 67.7±22.4kg. The flaps were harvested on intercostal and/or lateral thoracic arteries. All donor sites had been closed primarily. Following the classification of Dindo and Clavien, four minor complications (I, II), and two major complications (IIIb), including two hematomas requiring reoperation, were reported. No flap necrosis occurred. Follow-up averaged 27.9±8.4months. The patients' satisfaction with their improved breast shapes and chest wall contours was "good", with an aesthetic outcome mean ranked 3.8±0.8 (out of 5).

CONCLUSIONS

After MWL, upper body deformities can be treated safely and reliably by a combined approach, associating an UBL and autologous lateral chest wall perforator flaps to provide more natural and durable breast shapes, as well as an upper circumferential reshaping.

Clinical outcome of patients undergoing abdominoplasty after massive weight loss

BACKGROUND

Abdominoplasty is one of the most commonly performed surgical procedures to reshape the body contour in patients who have undergone massive weight loss.

OBJECTIVES

This study was undertaken to assess the clinical outcome, complication rates, and risk factors for complications of patients undergoing abdominoplasty after massive weight loss.

SETTING

University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

METHOD

Clinical outcome was retrospectively analyzed in 121 patients, who underwent abdominoplasty. The retrospective analysis included demographic data of patients, such as sex, age, body mass index (BMI), and pre-existing illnesses. Moreover, postoperative complications including seroma, hematoma, wound infection, and tissue necrosis were analyzed.

RESULTS

In our study cohort, the median age was 43.7 years, the median weight was 94.7 kg, and the median BMI was 32.3 kg/m². The majority of included patients were women (70.3%). Death occurred in none of the patients. Among individuals, wound infection occurred in 3.3%, tissue necrosis in 1.7%, seroma in 7.4%, and hematoma in 3.3% of patients during the postoperative course. Reoperations were necessary in 2 patients (1.7%) due to postoperative bleeding and tissue necrosis of the navel. Tissue necrosis was significantly more often seen in a subset individual with type 2 diabetes (P = .006). Moreover, the rate of reoperations was significantly higher in patients with pre-existing cardiovascular illnesses compared with cardiovascular healthy patients (P = .036). Multivariate analysis analyzing risk factors for postoperative complications, including sex, age, BMI, diabetes, pulmonary disease, and cardiovascular disease, revealed strong independent relevance for type 2 diabetes (P = .024).

CONCLUSIONS

We found that abdominoplasty is a safe operative procedure. In addition, the risk for complications is significantly increased in the subgroup of diabetic patients and patients with cardiovascular diseases.

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.

Fleur-de-lis Abdominoplasty and Neo-umbilicus

Body contouring for patients with massive weight loss may demand not only lifting but also some extent of central body tightening to achieve complete tissue readjustment. Although the fleur-de-lis procedure usually achieves nice contouring results, poor visible scars, including umbilical complications, have restricted the indications for the anterior vertical approach. The purpose of this article is to present the authors' experience with the inner scar umbilical reconstruction, enhancing overall results for vertical abdominoplasties. The inner scar umbilicus is a simple, safe, and reproducible technique, presenting low complication rates with sustainable and natural results.

Patient Evaluation and Surgical Staging

Comprehensive evaluation of the massive-weight-loss patient is a key factor to minimize complications while optimizing surgical outcomes. Special attention is given to medical and weight loss history, nutritional status, and physical examination. Massive-weight-loss patients often present with multiple areas of concern and therefore benefit from staged procedures. Staging requires knowledge on how the tissues are affected by each procedure and an understanding of the patient's priorities and goals.

Face and Neck Lifting After Weight Loss

After massive weight loss, deflation of the tissues and loss of skin elasticity in the face and neck can result in the appearance of accelerated facial aging. Surgical facial rejuvenation can be successfully performed with several modifications. Proper preoperative counseling and expectation management regarding staged or ancillary procedures is recommended. Wide undermining of the face and neck, and extended postauricular incisions are required to allow for mobilization of excess skin and access to the mobile superficial musculoaponeurotic system (SMAS). Fat transfer into the deep malar compartment for midface volumizing is helpful. Treatment of the SMAS and platysma are universally necessary.

Safety in Body Contouring to Avoid Complications

Body contouring after weight loss is becoming more prevalent. An appropriate systematic approach that starts from the first consultation needs to focus on residual comorbidities and weight of the patient. A thorough discussion about potential outcomes manages expectations. Preoperative optimization with smoking, herbal cessation, and nutritional assessment is mandatory. Planned staged approach minimizes lengthy procedures associated with increased postoperative morbidity. In the operating room, appropriate ambient temperature, positioning of the patient, and continuous discussion between surgeon and anesthesiologist prevent further complications. Careful transition to postoperative care with early ambulation and use of compressive garments add to an approach to minimize postoperative complications.

Arm Contouring in the Massive-Weight-Loss Patient

Brachioplasty is an increasingly popular procedure performed for improved arm contour in the massive-weight-loss population. There are challenging deformities presented in this population, such as redundant skin, posterior arm lipodystrophy, and loosening of fascial layers of the upper arm and chest wall that must be addressed to achieve successful contour of the arms. Common complications can be minimized with meticulous technique and knowledge of surgical anatomy. Additionally, brachioplasty can be combined with liposuction of the posterior arm as a safe and effective method for arm contouring without a higher risk of complications.

The M-Y Axilloplasty After Massive Weight Loss: Analysis of 159 Consecutive Patients

BACKGROUND

Brachioplasties often culminate in unsightly scars that are a source of disappointment to patients. We aimed to evaluate the results of M-Y axilloplasty following massive weight loss.

PATIENTS

We performed a retrospective assessment of our technique for brachioplasty with an M-Y axilloplasty in 159 female patients after massive weight loss. This retrospective study covered a study period of 10 years.

METHOD

After substantial lipoaspiration, the incision is placed on the internal side of the arm, with an M-shaped axilloplasty.

RESULTS

The satisfaction rate was 154/159 (97%) and 120/159 (75.5%) being happy with their esthetic results. Nineteen percent (30/159) of the patients had complications and 12/159 (7.5%) underwent a surgical revision.

CONCLUSION

M-Y axilloplasty for brachioplasty is an effective procedure for treating women who are unhappy with their upper arms after massive weight loss. The satisfaction rate is high, and the result leaves no excess skin on the chest.

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 .

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.

Autologous Flap Gluteal Augmentation: Purse-String Technique

The ideal patient for purse-string gluteoplasty has buttock deflation and ptosis, and wishes to improve projection. Key elements of the procedure are buttock lifting combined with auto-augmentation, no undermining of auto-augmentation tissue, and use of a purse-string suture to enhance projection of auto-augmentation tissue. Purse-string gluteoplasty is a safe and effective technique to correct buttock ptosis and atrophy.

Dorsal median lipectomy (the arrow technique): A new approach for the treatment of the circumferential truncal skin and fatty tissue excess

The increase in the number of patients who undergo massive weight loss surgery has led to an increasing number of patients who complain of circumferential abdominal skin and soft tissue excess. Currently, the only surgical option to treat soft tissue excess is vertical median abdominal lipectomy (fleur-de-lys technique). However, many patients are reluctant to undergo this surgery because of the position of the scar. We presented a new surgical approach to manage circumferential excess - dorsal median lipectomy (arrow technique) - in which the dorsal scar is well-tolerated by patients.

Body contouring procedures in three or more anatomical areas are associated with long-term body mass index decrease in massive weight loss patients: A retrospective cohort study

BACKGROUND

Massive weight loss (MWL) patients who undergo body contouring plastic surgery (BCPS) display superior long-term weight maintenance. The effect of the number of anatomical areas contoured on weight dynamics is undetermined.

OBJECTIVES

To determine whether body mass index (BMI) dynamics following BCPS are associated with the number of anatomical areas operated.

METHODS

A retrospective cohort study was conducted. Study groups were defined by the number of anatomical areas operated (1, 2, and 3+). BMI velocity was defined as a ratio between BMI change following BCPS and follow-up time. Multinomial logistic regression was performed to assess the independent association with BMI velocity.

RESULTS

A total of 222 patients undergoing 513 BCPSs between 2009 and 2014 were included in the study (mean age 36.8 ± 10.9 years, 77% females). Group 3+ (n = 88) had a negative mean BMI velocity compared with positive values in Groups 1 and 2 (-0.11 ± 1.0 vs. 0.44 ± 1.4 and 0.03 ± 1.2, respectively; p = 0.03). Independent risk factors for positive BMI velocity (>0.5 kg/m²/year) included single anatomical area BCPS compared to three or more (OR = 3.37; CI 95% 1.24-9.14; p = 0.017) and psychiatric medication use (OR = 6.73; CI 95% 1.15-39.35; p = 0.034). Independent protective factors included diabetes mellitus (OR = 0.094; CI 95% 0.01-0.99; p = 0.049).

CONCLUSIONS

BCPS in three or more anatomical areas following MWL is associated with a long-term weight loss following BCPS. As part of the health strategy to maintain normal BMI values and achieve overall quality of life improvement in MWL patients, clinicians and health policy makers should positively consider recommending BCPS in multiple anatomical areas.

Postero-Inferior Pedicle Surgical Technique for the Treatment of Grade III Gynecomastia

INTRODUCTION

Surgical treatment of Grade III gynecomastia generally utilizes mastectomy techniques and free transplantation of the nipple-areola complex. Moreover, with rising obesity rates and the development of bariatric surgery, an increasing demand for correctional surgery for pseudogynecomastia has been observed, which is comparable to Grade III gynecomastia in terms of its surgical management. Here, we describe an innovative technique to deal with these new demands: fascio-cutaneous flap by postero-inferior pedicle.

MATERIALS AND METHODS

All patients in the Department of Plastic Surgery from our University Hospital suffering from Grade III gynecomastia or pseudogynecomastia underwent surgery via the postero-inferior pedicle flap technique. Briefly, we performed extensive liposuction of the infero-internal and infero-external mammary quadrants followed by liposuction of the deep tissues of the superior quadrants, except in the area of the pedicle. After removing the skin just above the dermis of the inferior quadrants and performing de-epithelialization of the postero-inferior pedicle flap, the thoracic flap was lowered and the areola transposed.

RESULTS

Nine patients underwent surgery between March 2015 and March 2016, and their results were collected prospectively. The mean patient age was 46.6 years, the mean weight was 94.2 kg, and the mean body mass index was 30.8 kg/m². In addition, the mean operative time was 132 min, the mean liposuction volume was 633 mL, the excised weight was 586 g, and the mean hospitalization and drainage durations were 3.8 days. No major complications occurred, no re-intervention was required, and no recurrence was found.

CONCLUSIONS

We report a new operative technique using a postero-inferior pedicle. Its main advantage is preservation of neurovascular function, which makes this a promising technique for patients who wish to maintain nipple sensitivity. This surgery is reliable and reproducible. We recommend it as the first line treatment for Grade III gynecomastia because of its low rate of major complications and favorable functional and esthetic results.

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 .

Circumferential Contouring of the Lower Trunk: Indications, Operative Techniques, and Outcomes-A Systematic Review

BACKGROUND

Increasing obesity prevalence and development of bariatric surgery have led to the development of skin re-draping techniques. Several contouring techniques have been described for treating the circumferential excess of the lower trunk.

MATERIALS AND METHODS

We performed a systematic review to summarize surgical indications, operative techniques, peri-operative management (nutritional supplementation, antibiotic prophylaxis, thrombo-prophylaxis), outcomes, complications, patient satisfaction, and impact on quality of life of circumferential contouring of the lower trunk procedures. A systematic review, based on the PRISMA criteria, was conducted using the Pubmed and Cochrane databases.

RESULTS

The review included 42 articles and 1748 operated patients. Two studies only were graded as level of evidence II; the others were graded as levels III to V. The most frequently reported indication was massive weight loss. All the described techniques derived either from belt lipectomy or lower bodylift. Belt lipectomy resulted in a posterior scar situated at the waistline and allowed a better correction of hip back rolls, whereas lower bodylift was more effective on buttock and lateral thigh ptosis. The most reported complication was wound dehiscence. Patient satisfaction and quality of life scores were high in all studies.

CONCLUSIONS

This review included a majority of low-level evidence studies that limit extrapolability of the results. Future randomized prospective studies may generate stronger evidence, with a standardization of surgical indications and operative techniques.

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 .

Implementation of national body contouring surgery guidelines following massive weight loss: A national cross-sectional survey of commissioning in England

INTRODUCTION

National guidelines for commissioning of body contouring surgery (BCS) following massive weight loss (MWL) in England were published in 2014. Nearly three-quarters of patients who have MWL seek BCS; however, access is known to vary according to the region. The aim of national guidelines was to standardise access. The purpose of this study was to determine implementation of the national guidelines by clinical commissioning groups (CCGs) in England.

MATERIALS AND METHODS

A cross-sectional, web-based survey was sent to all CCG chairs in England.

RESULTS

Of 211 potential respondents, 108 completed the survey or provided funding guidelines (response rate = 52%). Eight CCGs (7%) had implemented the guidelines. A total of 69 CCGs were aware of the new guidelines (64%), and 66 CCGs stated that they fund BCS after MWL (61%). A total of 81 CCGs (75%) identified local funding guidelines, while 15 CCGs (14%) cited individual funding requests (IFRs) as the means of accessing funding. To improve patient access to BCS; 58 of 65 respondents (89%) stated cost-effectiveness, whereas 56 of 75 respondents (75%) thought patient-reported outcome measures were key. Qualitative data to improve access included an integrated pathway from bariatric surgery to BCS, an improved evidence base and greater CCG finances. One CCG stated that it cannot afford to fund cosmetic procedures.

CONCLUSIONS

The purpose of national guidelines was to simplify the pathway to BCS after MWL and create fair distribution of funds across the country to needy patients; however, their uptake has been poor. Access to funding for BCS across England varies according to the location.

About 76 patients over 4years]

INTRODUCTION

Massive weight loss leads to important cutaneous deformities with physical and psychological repercussions for patients. Lower bodylift is a procedure, which can restore the body contour. The aim of this study is to evaluate satisfaction and quality of life in patients who underwent lower bodylift and to review the complications of these procedures.

MEANS AND METHODS

This is a retrospective study of 76 patients who underwent lower bodylift between 2012 and 2016. We reviewed the complications of these procedures. Satisfaction and quality of life were assessed using Body-QoL questionnaire.

RESULTS

Seventy-six patients were included with a mean age of 39.2years. The average body mass index was 27.6kg/m² with a mean weight of 71.2kg at the time of surgery and a mean weight loss of 48.6kg. Twenty-three patients developed one complication: 22 minor and 1 major. Forty-eight patients answered the questionnaire. Satisfaction was rated "very good" by 41 patients (85.4%) and "good" by 5 patients (10.4%). The Body-QoL questionnaire's analysis showed an improvement of quality of life socially, sexually, in the body regard and in physical symptoms.

CONCLUSIONS

Lower bodylift is the only procedure, which can restore circumferential body contour. Despite the minor complications reviewed, the degree of satisfaction of the patients is very high. The quality of life of these patients, after massive weight loss, is also highly improved by these procedures. With the worldwide development of obesity and bariatric surgery, this study demonstrated that the operation should be proposed to patients with massive weight loss to improve quality of life.

Prevalence and factors associated with persistent pain following body contouring surgery

BACKGROUND AND AIM

Persistent postsurgical pain (PPP) has been reported by patients following various surgeries. Body contouring procedures are being performed more frequently, but no data are available regarding the effects of these procedures. Long-term disability occurring after performing "functional" procedures on healthy subjects is a particular concern. The aim of this study was to describe the risk factors, prevalence, characteristics, and effects of persistent pain after body contouring procedures.

METHODS

Patients who underwent body contouring surgery (e.g., abdominoplasty, lower body lift, medial thigh lift, brachioplasty, and abdominal liposuction) between January 1 2009 and December 31 2013 were included in this retrospective, monocentric cohort study. Pain evaluation was performed using a visual analog pain scale (VAS) and the Douleur Neuropathique 4 (DN4) questionnaire. Major risk factors previously identified in the literature were evaluated.

RESULTS

The study included 199 patients. Pain was reported by 42 patients (21%). Seventy-one percent (n = 30) of these 42 patients presented with neuropathic pain. Risk factors that were significantly associated with PPP were acute postoperative pain (p = 0.0003), medical history of bariatric surgery (p = 0.002), longer period of hospitalization (p = 0.04), depressive status during the operative period (p = 0.03), substantial stress before surgery (p = 0.03), and major complications after surgery (p = 0.03).

CONCLUSION

Persistent chronic pain is frequent after body contouring procedures. Preemptive approaches and early postoperative diagnosis are important measures that can be used to limit the effects of this complication on the patient's quality of life.

Introducing the Body-QoL®: A New Patient-Reported Outcome Instrument for Measuring Body Satisfaction-Related Quality of Life in Aesthetic and Post-bariatric Body Contouring Patients

OBJECTIVE

To develop a new patient-reported outcome instrument (PRO) to measure body-related satisfaction quality of life (QoL).

METHODS

Standard 3-phase PRO design was followed; in the first phase, a qualitative design was used in 45 patients to develop a conceptual framework and to create preliminary scale domains and items. In phase 2, large-scale population testing on 1340 subjects was performed to reduce items and domains. In phase 3, final testing of the developed instrument on 34 patients was performed. Statistics used include Factor, RASCH, and multivariate regression analysis. Psychometric properties measured were internal reliability, item-rest, item-test, and test-retest correlations.

RESULTS

The PRO-developed instrument is composed of four domains (satisfaction with the abdomen, sex life, self-esteem and social life, and physical symptoms) and 20 items in total. The score can range from 20 (worst) to 100 (best). Responsiveness was 100 %, internal reliability 93.3 %, and test-retest concordance 97.7 %. Body image-related QoL was superior in men than women (p < 0.001) and decreased with increasing age (p = 0.004) and BMI (p < 0.001). Post-bariatric body contouring patients score lower than cosmetic patients in all domains of the Body-QoL instrument (p < 0.001). After surgery, the score improves by on average 21.9 ± 16.9 (effect size 1.8, p < 0.001).

CONCLUSIONS

Body satisfaction-related QoL can be measured reliably with the Body-QoL instrument. It can be used to quantify the improvement in cosmetic and post-bariatric patients including non- or minimally invasive procedures, suction assisted lipectomy, abdominoplasty, lipoabdominoplasty, and lower body lift and to give an evidence-based approach to standard practice.

LEVEL OF EVIDENCE I

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.

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.

A preliminary report on the development of a validated tool for measuring psychosocial outcomes for massive weight loss patients

AIM

To validate the newly developed patient report outcome measure (PROM): the Post Bariatric Outcome Tool (PBOT). The tool is designed and developed for massive weight loss patients seeking body contouring procedures.

METHOD

The PBOT was piloted with three cohorts: massive weight loss patients seeking body contouring; massive weight loss patients who have had body contouring; and healthy, non-obese subjects as controls matched for age and gender. Each cohort completed two PROMS at week one, and then for a second time at week three. The PROMS used were the new Post Bariatric Outcome Tool (PBOT) and the Derriford Appearance Scale 24 (DAS24).

CONCLUSION

The PBOT was shown to be reliable both in terms of its internal consistency and test-retest reliability. Comparison to the DAS24 demonstrated the PBOT to be valid. However, the cohorts were small and responsiveness was not tested. This needs to be tested in further larger validation studies, ideally, with comparison to functional scales such as the SF-36 or other validated massive weight loss body contouring PROMs; such as the Body Q.