Body and Extremity Contouring After Massive Weight Loss

Body and Extremity Contouring after Massive Weight Loss

Joseph F. Capella

Body contouring after massive weight loss (MWL) is inherently challenging. The challenges relate to the severity of the deformities, the relatively poor quality of the tissues, and the comorbidities that are often present in patients who have had bariatric surgery. Unfavorable results are commonly the result of these inherent challenges but may also be secondary to choices made by the surgeon in formulating an approach to address patient concerns. Suboptimal choices may be influenced by many variables, including the following:

• Application of routine body contouring procedures to a patient who has had bariatric surgery

• Patient or surgeon desire to minimize scars

• Simultaneous performance of procedures with opposite vectors of tension

Post–bariatric-surgery deformities derive from individuals being in an obese state for variable periods of time. Pockets of excess fat produce increased tension on skin and the underlying connective tissues. Greater time in an obese state and a higher weight produce greater tissue damage. Through weight loss and the metabolism of fat and potentially protein (muscle wasting), the tension on the soft tissue envelope diminishes, and the failure of the damaged soft tissue envelope to retract completely leads to the characteristic appearance of an individual who has had bariatric surgery (Fig. 31.1). Aside from the patient’s length of time in the obese state, the deformity is influenced by factors such as genetics, exposure to environmental agents such as ultraviolet light, tobacco consumption, and the age of onset of obesity. Individuals who gain and lose weight as teenagers will usually have less sequelae than older individuals. In addition, gender greatly affects the characteristics of the weight loss deformity: The deformity in men is quite consistent, whereas that of women varies from a gynoid body type to a more android body habitus (Fig. 31.2).

Obese individuals often suffer multiple comorbidities, including heart disease, hypertension, diabetes mellitus, osteoarthritis, and breathing problems such as sleep apnea and asthma.¹ After weight loss many of these conditions may be improved but not be entirely resolved. The residual effects of these illnesses may affect wound healing and early ambulation, complicating the recovery of potentially extensive surgical procedures. Furthermore, the average MWL patient is overweight at the time of body contouring, representing a risk factor in and of itself.²

Body contouring after weight loss is a relatively new specialty within plastic surgery. Before 2000 very few of these procedures were being performed, and even today many practicing plastic surgeons did not receive formal instruction in this discipline as part of their training.³ Limited exposure to this patient population may lead to an incomplete understanding of these deformities and of the application of traditional body contouring procedures to the MWL patient, resulting in less than optimal outcomes. The magnitude and extent of the MWL deformity is usually far greater than in the traditional body contouring patient. Therefore many regions of the body often need to be addressed to satisfy patient concerns. The typical MWL patient is in the third or fourth decade of life, is very active, and usually wants the fewest scars and the quickest possible recovery in achieving their goals.² The plastic surgeon, in an effort to accommodate patient requests, may perform short-scar versions of procedures and multiple operations simultaneously with opposite vectors of tension with unfavorable results.

The severity of the MWL deformity and the emotional and functional toll it presents for many individuals provides the plastic surgeon with an opportunity to provide a high level of satisfaction. The focus of this chapter is on minimizing complications and unfavorable results after brachioplasty, vertical medial thigh lifts, and circumferential lower body lifts.

Fig. 31.1 (a–c) A 27-year-old man 12 months after weight loss of 225 lbs. through lifestyle changes. His weight here was 175 lbs., and his body mass index (BMI) was 27. His peak weight and BMI were 400 lbs. and 61, respectively. (d–f) A 55-year-old woman 13 months after gastric bypass surgery and weight loss of 115 lbs. Her weight here was 156 lbs., and her BMI was 30. Her peak weight and BMI were 271 lbs. and 53, respectively. The patient has a gynoid body type.

Avoiding Unfavorable Results and Complications in Body Contouring After Massive Weight Loss

Complication rates and the potential for unfavorable outcomes are greater in MWL contouring than traditional body contouring.4–6 To manage patients who have had bariatric surgery safely and effectively, every effort should be made to screen patients appropriately, minimize and manage complications effectively, and make the best surgical choices in addressing their contour deformities. Complications after different body contouring procedures for patients who have had bariatric surgery are similar, but the rates vary between extremity and truncal contouring procedures, with truncal procedures having a higher rate of more serious complications.^4–6 Unfavorable results may be the result of complications but more often are the consequence of deficiencies in preoperative screening and education and surgical choices.

Fig. 31.2 A 50-year-old woman 42 months after gastric bypass surgery and weight loss of 80 lbs. Her weight here was 170 lbs. and her body mass index (BMI) was 31. Her peak weight and BMI were 250 lbs. and 46, respectively. The patient has an android body type.

Summary Box

Patient Outcome Data of Complications

Preoperative Planning and Patient Selection

Avoiding complications and unfavorable outcomes begins with careful patient selection, education, and planning. Initial consultation should include a detailed history with an emphasis on weight, a focused physical examination, and a thorough discussion of the patient’s goals.7 MWL is usually a result of bariatric surgery and less often changes in lifestyle. Bariatric surgical procedures tend to produce rapid weight loss, with weight stability achieved within 18 months.⁸ Lifestyle changes usually produce slower weight loss and have higher rates of recidivism. Important compo nents of weight history to obtain are the patient’s highest weight, length of time at this weight, current weight, and length of time at this weight. Physical examination should focus on the region of the body where the patient has expressed concerns but should also make note of the extent of the deformity of the adjoining regions. Scars, striae, intertrigo, hernias, degree of fascial laxity, edema, skin sequelae relating to edema, and the extent of soft tissue excess should be documented. Images should be obtained of the relevant areas of the body. The initial visit, in addition to developing rapport, should serve as a critical opportunity to gain a clear understanding of the patient’s goals, expectations, and tolerance for scars. In addition, existing work, family, and financial constraints should be explored.

Surgery should be deferred in individuals whose weight is not stable. Significant, active weight loss can result in metabolic imbalances that may result in poor healing and an early recurrence of soft tissue excess. Ideally, patients should be at a stable weight for several months, but more importantly, they should have a healthy metabolic profile. Surgery should be discouraged in individuals with unrealistic expectations both regarding the expected outcome and the recovery process. Patients seeking outcomes similar to individuals with very different profiles, such as lower body mass index (BMI), smaller BMI change, and younger age, will invariably be disappointed. Individuals whose finances are limited and for whom unforeseen expenses could cause disruption in their lives should be discouraged from having surgery. In addition, surgery should be avoided in cases where the motivation for surgery is unclear or when surgery is requested by someone other than the patient.

The history, physical examination, and discussion of goals and expectations provide much of the information needed for the education component of the initial consultation. Patient education should include a discussion about complications and should be tailored to the information gathered from the history and physical examination. Although complications are never a pleasant occurrence, they are much better tolerated and perceived very differently by patients who are accurately informed of the likelihood of these adverse events and how they are managed. Every effort should be made at the first office visit to educate patients about expected outcomes and to highlight elements of their history and examination that may lead to an unfavorable outcome. Before and after images of individuals with similar patient profiles, including age, BMI, BMI change, body type, and deformity, can be very helpful and provide candidates with an accurate perspective on likely outcomes. Scars and their management should be reviewed.

At the conclusion of the initial consultation, a plan can be formulated and discussed with the patient. Safety should always be the first priority, and in any plan every effort should be made to account for the generalized soft tissue excess, avoid opposing vectors of tension, and minimize scar perceptibility.

An office visit before surgery should serve as an opportunity to answer any remaining patient questions; review potential complications and their management; and discuss preoperative and postoperative guidelines, laboratory values, and consultations. One of the most important components of the second office visit is to discuss the images taken at the first visit. Areas to be addressed by the proposed surgery and the regions not affected by the procedure should be noted. Features that may lead to an unfavorable outcome should be highlighted once again. At this visit, we advise patients that they will be weighed immediately before surgery and that all tissues removed during surgery will be weighed. The importance of maintaining the weight from the day of surgery minus what was removed at the time of surgery is clearly explained to the patients. These values are recorded in the patient’s chart and their significance reiterated at follow-up visits.

Managing Complications in Body Contouring After Massive Weigh Loss

Extremity Contouring

Skin Dehiscence

Complications after extremity contouring and truncal contouring are similar but differ in frequency (see Summary Box). The most common complication after extremity contouring, brachioplasty, or vertical medial thigh lift, is skin dehiscence at the junction of the extremity with the torso. The wounds tend to be small, 2 to 3 cm in length, and present approximately 10 to 14 days after surgery. The complication can be attributed to the wide range of motion at the arm–or thigh–torso interface, the moisture that is often present in these areas, and relative soft tissue ischemia at the confluence of scars at the axilla or groin. Excessive tension at closure may be a contributing factor as well. Management of this complication is usually limited to dry dressing changes. In most instances the wounds are closed by 6 weeks. On occasion, when hypergranulation tissue forms, the application of silver nitrate may be needed (Fig. 31.3). Efforts to prevent this complication by avoiding scars at this junction will invariably adversely affect the aesthetic outcome.

Fig. 31.3 Hypergranulation tissue at the left axilla of a 46-year-old woman 6 weeks after bilateral brachioplasty. Silver nitrate has been applied to area.

Seromas

Seromas are the second most common complication after extremity contouring. The fluid collections form immediately beneath the closure along the distal one third of the extremity. The cause may be attributable to motion at the elbow or knee. Needle aspiration is associated with a high recurrence rate. Marsupialization of the bursa leads to a prolonged healing process and a potentially unacceptable scar. Placement of a Penrose drain into the fluid pocket for a period of 1 week or until drainage is minimal has proven to be highly effective and well tolerated by patients (Fig. 31.4). Antibiotics are prescribed while the drain is in place.

Other Complications

Complications such as skin necrosis, infection, and thromboembolism are rare. Prolonged edema, though often associated with medial thigh lift procedures, has not been a concern in our series. A key element to avoiding this complication is maintaining dissection at a superficial level in the region of the femoral triangle. After MWL patients may present with chronic stable edema. In those cases, patients return to their baseline level of edema within 3 months of surgery. We do not routinely prescribe extremity garments postoperatively in extremity contouring. Upper extremity garments produce swelling of the hand and do not appear to improve outcomes. If patients develop foot and leg swelling after medial thigh lift, lower extremity compression garments are advised. Patients with a presentation more suggestive of thromboembolic disease are further evaluated.

Body Lifts

Skin Dehiscence

The more extensive nature of truncal contouring, particularly circumferential lower body lifts, leads to more serious and higher rates of complications. Most skin dehiscences are at the buttock cleft (Fig. 31.5). The separation typically becomes apparent between 10 and 14 days postoperatively and is mostly the result of tissue ischemia. Diminished tissue perfusion to this region can be attributed to tension in the area while patients are flexed at the waist, the inelastic quality of the zone of adherence of the midline back, and direct pressure over the coccyx bone. Another important factor is persistent moisture in a deep buttock cleft. Particularly in women with a more gynoid body habitus, where the lower body circumference is far greater than the upper body, the directly opposing skin surfaces are conducive to moisture retention and skin breakdown. The problem of moisture is further exacerbated when leakage of serous fluid occurs at the cleft. This complication is effectively managed with dry dressing changes and silver nitrate application when needed. Efforts to diminish the frequency of this complication include minimal tension in the performance of the procedure in the region of the cleft and patient guidelines to avoid excessive flexion at the waist and prolonged periods in a recumbent position during the first several weeks postoperatively. More recently, we have advised our patients to keep a dry dressing in the cleft beginning from the immediate postoperative period to avoid any moisture in this area.

Fig. 31.4 Penrose drain placed into seroma cavity along distal medial arm after brachioplasty.

Fig. 31.5 (a) Buttock cleft skin dehiscence at approximately 2 weeks postoperatively. (b) Appearance at approximately 4 weeks postoperatively.

Fig. 31.6 (a) This 27-year-old woman was disappointed with an early recurrence of soft tissue excess along the lateral thigh 1 year after a body lift. (b) A bursa secondary to a seroma was discovered at the time of lateral thigh revision.

Seromas

The management of seromas after lower body lifts is challenging. The frequency of this complication is the result of the extensive nature of this procedure and shearing of tissue surfaces. Our primary approach to minimizing seroma formation is with the placement of five drains intraoperatively, with one specifically in the epigastric region. Seromas are usually not noted by patients and may be easily missed by the surgeon. Management begins preoperatively when patients are educated on seromas. We advise them that a resulting bursa may adversely affect their aesthetic outcome by not allowing their skin envelope to adhere to the deeper structures (Fig. 31.6). We also advise patients on how to recognize seromas. Regardless, seromas can of ten be subtle and go undetected by patients. Consequently, one of the most important reasons for a 6-week follow-up visit is to assess patients for seromas. In our patient population, seromas are typically found in the hip region and are effectively managed by needle aspiration. To prevent the formation of a bursa, we advise patients to come every few days to resolve the seroma as quickly as possible. For patients who live far from our office or when seromas appear to be large (larger than 200 mL), we often introduce a Jackson-Pratt drain into the seroma cavity through the patient’s existing scar. We have not needed sclerosing agents or any other modalities to resolve seromas. Efforts to minimize seroma formation by the placement of quilting stiches has proven unsuccessful.

Skin Necrosis

Skin necrosis is an ongoing concern with lower body lifts, as it is with any procedure involving a full abdominoplasty. Most cases occur along the suprapubic region, and risk factors include tobacco consumption, abdominal wall scars, excessive undermining and tension, and liposuction. Undermining in abdominoplasty should be limited to the fascia overlying the rectus muscle in the epigastric region. If an epigastric roll results from this limited dissection, particularly after fascial plication, additional digital dissection, scissor spreading, or liposuction can smooth this region. In an effort to maintain the vascularity of the flap, liposuction should be limited to the epigastric portion of the abdomen. Excess fat deep to the superficial fascial system in the hypogastric portion can be directly excised. Patients with existing transverse or oblique epigastric scars need to be assessed on an individual basis. Those with older scars in the epigastric region may still benefit from abdominoplasty; however, undermining in the epigastric region should be very limited. Candidates with newer scars in this region should be avoided altogether. Smokers should be informed of the risks associated with tobacco consumption during the preoperative evaluation and advised to stop for 6 weeks before and after surgery. Laboratory tests and affirmation from patients will not guarantee that they are not smoking, so if surgery is considered in this patient population, limited undermining and flap tension and careful use of liposuction are particularly important. To minimize the potential for flap ischemia, our patients are kept in a beach chair position for several days postoperatively and binders are placed loosely with the primary function of holding sterile dressings in place. Flap ischemia and the potential for necrosis usually becomes apparent within 24 hours. If an area appears to be ischemic, nitroglycerin paste can be applied, although we have not seen significant benefit from this therapy. Any external factor, such as a tight binder of constrictive dressing, should be eliminated. Silver sulfadiazine cream 1% should be applied to the area if signs of skin breakdown, such as blister formation, become apparent. Moist-to-dry dressing changes become the mainstay of management if tissue necrosis develops. Sharp débridement at the bedside can be implemented as well with careful attention to not remove viable tissue. Once granulation tissue has formed and wound contracture begins, soft tissue defects will become considerably smaller. Our preference is to allow these wounds to heal by secondary intention and consider scar revision 1 year postoperatively.

Infections

Infections, particularly those requiring intravenous antibiotics, are uncommon after lower body lifts. To reduce the risk of this complication, patients are advised to bath with chlorhexidine the day before surgery and are given intravenous antibiotics before the first surgical incision. Patients are prepped standing, and sterile technique is followed throughout the procedure. Intraoperatively, tissue manipulation is minimized and cutting is used over cautery whenever possible. Antibiotics may be redosed during surgery, depending on the length of the procedure. Postoperatively first generation cephalosporins are prescribed while drains are in place, usually for 2 weeks. Infections possibly requiring intravenous antibiotics usually become clinically evident at 7 to 10 days postoperatively and may be associated with erythema and induration along the incisions, tenderness, elevated temperatures, and purulent discharge through the drains or drain incisions. Hospital admission is usually required. Computed tomography should be performed to evaluate for a possible collection requiring drainage, and consultation with an infectious disease specialist should be considered. Ex isting drains often serve as a nidus of infection and should be removed.