Body Contouring Following Bariatric Surgery And Massive Weight Loss: Post-Bariatric Body Contouring

Overweight and obesity have reached epidemic proportions, with more than 1 billion adults overweight globally. Childhood obesity is already epidemic in some areas and on a rise in others. An estimated 22 million children under age five are considered to be overweight worldwide. The rising obesity epidemic reflects profound changes in society and in the behavioral patterns of communities over the recent decades. There is a variety of factors that play a role in obesity which makes it a complex health issue to address; nevertheless, overweight and obesity are primarily diet-induced. The principal causes of the epidemic are first a sustained excess in ingestion of energy-dense foods and second an increasingly sedentary lifestyle. Although obesity should be considered an avoidable chronic disease in its own right, it is also one of the most substantial key risk factors for other chronic diseases. The morbidities associated with obesity reduce a patient's quality of life and contribute to escalating medical costs.

Bariatric surgical procedures were designed and developed to induce weight loss and hence improve or eliminate obesity related co-morbidities. The field of bariatric surgery has grown appreciably over the last decade with a rapid rise in the utilization of bariatric surgery worldwide, partly fueled by the introduction of minimally invasive surgery techniques and partly by the growing epidemic of obesity. This chapter reviews the most common bariatric operations performed with emphasis on technique, short and long-term outcomes.

Bariatric surgery is the only and effective treatment for morbid obesity and leads to diabetes remission. The mechanism of action is reviewed in this chapter. The role of gut hormones as facilitators of appetite control, weight loss and an improved glycemic control after bariatric surgery is described. Furthermore nutritional considerations and their management after bariatric surgery are discussed.

The objective of the present chapter is to understand the gamut meanings for patients when undergoing bariatric surgery, the impact that this represents in their lives, the psychosocial complications and to offer some recommendations for a better psychological evolution of patients undergoing bariatric surgery.

Bariatric surgery is a procedure that results in a complex network of emotional experiences. The main emotional experiences in the post-operative procedures are: social re-insertion, personal acceptance, risk of disillusion, recovery of self esteem, improvement in quality of life and body image. Body contouring following a significant weight loss can re-establish a good psychosocial functioning, but it must be stated with well-established criteria. Some practical considerations to deal with the operated patients are proposed.

Popularity of bariatric surgery has increased exponentially over the past several years. As a result, a new patient’s population has emerged seeking plastic surgery: the Massive Weight Loss (MWL) patient. Patients who experience MWL present with bi-dimensional skin excess and are left looking “deflated,” with disfiguring skin laxity circumferentially around the torso, including the breasts, redundant tissue on the upper arms, buttocks, and thighs leading to poor social acceptance and quality of life.

The strength with which the superficial fascia attaches to the underlying muscular fascia varies throughout the body. Areas of high strength are called zones of adherence and usually excessive tissue laxity are especially evident in these zones of decreased adherence. Post-bariatric weight loss contour deformities well exceed contour deformities plastic surgeons have ever encountered previously. These deformities are diverse and often severe in nature. It is not possible however to predict where body contouring deformities will materialize because they may be present anywhere on the body. Nevertheless their accurate classification can assist the surgeon in operative planning.

Massive Weight Loss (MWL) patients differ from other patients in several parameters. They are at an increased risk for complications secondary to potential nutritional deficiencies, persistent obesity, venous varicosities, poor quality and inelastic tissue. As the numbers of patients who seek body contouring after extreme weight loss increase, surgeons must be able to inform patients of the risks and complications of body-contouring surgery as they relate to the specific co-morbidities of the particular patient. Likewise, surgeons will need to alter the aggressiveness of the procedure according to the risk versus benefit in patients who fall into higher-risk groups. The foundation for a safe body contouring practice involves a combination of good patient selection and managing patient expectations. Appropriate pre-operative assessment intra- and post-operative care as well as selection of the appropriate timing, type, and magnitude of surgery are all essential.

Patients requiring surgical skin excision after massive weight loss are challenging and require an individualized and structured approach. The characteristic abdominal deformity includes a draping apron of panniculus often extending to the back, gluteal and thigh areas. Occasionally these deformities are associated with previous surgical scars in the upper abdomen resulting from open gastric bypass surgery or from other procedures such as open cholecystectomy. These scars can compromise the blood supply of the abdominal skin. For adequate and safe abdominal contouring both excess skin and fat as well as the remaining perfusion of the remaining tissues must be addressed to achieve satisfactory results. The key to satisfactory results is a thorough analysis of horizontal and vertical skin and fat excess of abdominal area keeping in mind the torso, buttock, flank areas and choosing an adequate and safe procedure addressing the respective areas of skin and fat excess while preserving the blood supply of the abdominal area in a scarred abdomen.

Thigh lifting for excess soft tissue and skin laxity became an essential part of the lower body contouring after massive weight loss. Since early 1950’s, thigh deformity and different techniques of thigh lift have been addressed. In this chapter, we address and review the anatomical considerations of the different procedures of medial thigh lift and lateral thigh lift as well as the combined techniques.

Gluteal deformities encountered in patients who have lost a massive amount of weight are unprecedented in body-contouring surgery and plastic surgeons need uncommon techniques when contouring and augmenting the gluteal region in these patients. Following massive weight loss, a lot of patients show atrophy in their buttocks. In addition to the skin laxity and the volume loss relaxation of the superficial fascial apron contributes to gluteal ptosis as well. To restore a youthful gluteal contour, part of the tissue normally resected in circumferential lower body lift can be used enhancing gluteal contour with autologous tissue augmentation. Gluteal aesthetics in massive weight loss patients can be achieved also with large volume autologous fat transfer or alloplastic implants. Adjunctive techniques such as resection and tightening of the gluteal superficial fascia system (gluteal SMAS), posterior thigh lift and infragluteal diamond lift can refine the results.

Massive weight loss patients present characteristic breast deformities. Most of the techniques developed for correcting typically enlarged or ptotic breasts fail in this patient group, instead more complex and challenging manipulations are usually needed. Selection of the surgical technique is mainly based on the available breast volume. An algorithm for surgical correction of breast deformities following massive weight loss is presented.

Gynecomastia is an extremely disturbing deformity especially when it occurs in young male adolescents. It is of frequent occurrence in obese persons and even more so after severe weight loss. Following massive weight loss, there is excessive redundancy of the skin breast mound as well as the chest skin around it. This deformity needs to be corrected to regain a male chest contour or if possible, even better a masculine or an ideal male's chest wall appearance. Gynecomastia following massive weight loss can be classified in only two categories based on the required correction. Type 1 gynecomastia characterized by mild skin redundancy or breast ptosis that can be corrected by concentric circumareolar excision of the excess skin and Type 2 gynecomastia characterized by major skin redundancy and breast ptosis that necessitates excision of chest wall skin with shifting of the nipple position for correction.

The male chest appears that of females in patients with gynecomastia and in patients presenting after huge weight loss. The disadvantages of reduction mammaplasty in men are the visible scars on the chest wall. The aim of the chest lifting is to reposition the breast in a male appearance by thinning the amount of glandular and fatty tissue and avoiding noticeable scars in the chest wall, the wound being hidden in the anterior axillary line.

Management of excessive laxity of the abdomen, breasts, arms, thighs and buttocks following massive weight loss has received much attention, however little has been written about the surgical approach to the back rolls and folds. “Back rolls” can range in a number from one to four on either sides of the midline. In post-bariatric patients, the excess tissue must be excised. Liposuction is rarely indicated because the skin and subcutaneous tissue remains in excess in these patients. In addition, back tissue is dense and fibrous, making it less amenable to liposuction. Post-bariatric contouring of back-roll deformities requires an approach that allows for direct excision of the two lower folds (lower thoracic and hip rolls) during the circumferential lower body lift procedure and of the two upper folds.

The arms represent a challenge in body contouring surgery. Deformities of the upper arms vary in presentation from minor defects to extensive skin excesses. When skin elasticity is good and fatty deposits limited, traditional forms of liposuction may be utilized. In the massive weight loss patient, the deformity often encountered is that of extensive excess skin, which will be the subject of discussion in this chapter.

The face is the window of the person to the surrounding world and the eyes are the avenue to his soul. Having started with this concept that we have in craniofacial surgery, we can look then at the patients in our daily practice and see how this part of the body presents the most important aesthetic unit that needs to be corrected especially after bariatric surgery and massive weight loss. As more patients become aware of the obesity issues, they will seek more help to put them. Their psyche and their bodies on track by cutting off the fat, they have accumulated over the years some from teen years. After the loss of adipose tissue, patients focus on the remaining excessive skin they have developed over the obese years. The part that people look at especially in a conservative society is the face and secondarily the neck when they are well dressed and mingling with friends and acquaintances. The face is divided into the upper components and the lower components engulfing the neck and jaws. The face is the first to show the reflection of obesity and the last to show the effect of changes in body fat composition. Contouring the face is part of the plastic surgery principles to complete the changes after the patient departs from the obesity stigma. Complications are minimal when the surgeon abides by the basic principles and rules of plastic surgery.

Obesity is a major health problem throughout the world. Its management by bariatric surgical interventions is associated with a good success rate, leading to a necessary removal of excess skin after weight loss. The popularity of bariatric surgery has created this new patient population characterized by major anatomical and physiological changes with Massive Weight Loss (MWL) who still maintains many of the co-morbidities of obesity. As a part of a multidisciplinary management, anesthetic management of these patients should take the specific problems into consideration associated with obesity and optimize them before surgery. All these factors such as physical changes, co-morbid medical conditions (pulmonary, cardiovascular and metabolic changes such as vitamin deficiencies etc.), airway difficulty, propensity for venous thrombosis, embolism, patient positioning, avoidance of hypothermia, pharmacodynamics and pharmacokinetics of anesthetics and changes related to bariatric surgery as well are all addressed in this chapter.

Another important aspect that is addressed is the role of regional anesthesia and its advantages over general anesthesia for these patients, taking into consideration the difficulty in palpating bony landmarks or even identifying the midline because of skin laxity and residual excess adipose tissue and therefore neuroaxial blockade could be challenging.

Finally the postoperative management is optimized by development of clinical pathways involving the surgeon, anesthesiologist, patient and support staff. Although obvious physical and physiological improvement may be attained by such surgical procedures, the patient must be fully informed of the multiple risks and complications inherent in such procedures.