The obesity pandemic has resulted in increasing cases of bariatric surgery and subsequent issues related to excess skin and laxity for patients. This patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the issues of the body contouring candidate and provides tools that may assist in surgical planning.
Key points
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Body contouring after massive weight loss is often the final phase of a long and positive journey for the bariatric patient.
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As the prevalence of obesity increases and many more continue to seek bariatric and subsequently body contouring surgery, it is critical that plastic surgeons become well versed in not only techniques that address skin laxity, but also more familiar with the unique set of issues that the postbariatric patient presents.
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A careful and comprehensive approach like the one presented in this article allows for safe and effective treatment of these patients.
Introduction
As a result of the obesity pandemic, more and more individuals are seeking bariatric surgery for weight loss and resolution of conditions related to obesity. As the numbers have risen to greater than 200,000 cases per year, the number of postbariatric massive weight loss patients presenting to the plastic surgeon for body contouring to address excess skin laxity is increasing. However, this patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the body contouring candidate and provides tools that may assist in surgical planning.
We have identified six key assessment points as part of a comprehensive evaluation of the massive weight loss patient presenting for potential body contouring surgery: (1) time from gastric bypass to body contouring procedures; (2) body mass index (BMI) at presentation; (3) evaluation of medical comorbidities; (4) nutritional assessment; (5) psychosocial status; and (6) physical deformities and potential for combined procedures. An overview of these points is presented in Box 1 .
BMI
Best candidates have reached a BMI <30
Functional operations preferred for higher BMIs with associated physical impairments
Timing
Minimum 12 mo after bariatric surgery
Weight stability for a minimum of 3 mo
Medical comorbidities
Many resolve following bariatric surgery, but residual disease states must be investigated
Tight glycemic control for diabetics
Cardiac evaluation for patients with concerning symptoms or sedentary lifestyle
Rigorous work-up for history of deep venous thrombosis or pulmonary embolism and prophylaxis
Appropriate use of medical consultants
Nutritional status
Identify type of bariatric procedure performed
Assess protein intake by history, with a goal of 70–100 g/day before body contouring surgery
Document supplements used
Assess for signs of micronutrient deficiency
Supplement micronutrients (eg, iron, vitamin B 12 , calcium) as needed
Refer patient back to bariatric surgeon if there is protracted nausea/vomiting or weight loss plateau at unacceptably high BMI
Psychological status
Establish rapport early in initial consultation
Ask patients to describe their concerns and clearly delineate goals and priorities in their own words
Emphasize the tradeoff of skin for scar
Assess for reasonable patient expectations
Depression is pervasive
Evaluate for physical and emotional support networks
Patients with known or suspected body dysmorphic disorder, bipolar disorder, or schizophrenia should undergo a mental health evaluation
Introduction
As a result of the obesity pandemic, more and more individuals are seeking bariatric surgery for weight loss and resolution of conditions related to obesity. As the numbers have risen to greater than 200,000 cases per year, the number of postbariatric massive weight loss patients presenting to the plastic surgeon for body contouring to address excess skin laxity is increasing. However, this patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the body contouring candidate and provides tools that may assist in surgical planning.
We have identified six key assessment points as part of a comprehensive evaluation of the massive weight loss patient presenting for potential body contouring surgery: (1) time from gastric bypass to body contouring procedures; (2) body mass index (BMI) at presentation; (3) evaluation of medical comorbidities; (4) nutritional assessment; (5) psychosocial status; and (6) physical deformities and potential for combined procedures. An overview of these points is presented in Box 1 .
BMI
Best candidates have reached a BMI <30
Functional operations preferred for higher BMIs with associated physical impairments
Timing
Minimum 12 mo after bariatric surgery
Weight stability for a minimum of 3 mo
Medical comorbidities
Many resolve following bariatric surgery, but residual disease states must be investigated
Tight glycemic control for diabetics
Cardiac evaluation for patients with concerning symptoms or sedentary lifestyle
Rigorous work-up for history of deep venous thrombosis or pulmonary embolism and prophylaxis
Appropriate use of medical consultants
Nutritional status
Identify type of bariatric procedure performed
Assess protein intake by history, with a goal of 70–100 g/day before body contouring surgery
Document supplements used
Assess for signs of micronutrient deficiency
Supplement micronutrients (eg, iron, vitamin B 12 , calcium) as needed
Refer patient back to bariatric surgeon if there is protracted nausea/vomiting or weight loss plateau at unacceptably high BMI
Psychological status
Establish rapport early in initial consultation
Ask patients to describe their concerns and clearly delineate goals and priorities in their own words
Emphasize the tradeoff of skin for scar
Assess for reasonable patient expectations
Depression is pervasive
Evaluate for physical and emotional support networks
Patients with known or suspected body dysmorphic disorder, bipolar disorder, or schizophrenia should undergo a mental health evaluation
Preoperative evaluation and procedure timing
Initial preoperative history should focus on age of onset of obesity, family history of obesity, type and date of bariatric surgery performed, and course of weight loss since surgery. Anthropometric measures should include height, weight (highest, lowest, and current), and BMI. Determination regarding patient’s weight stability should be made because many patients have a 12- to 18-month period of continued weight loss after their bariatric surgery. Inquiry into weight changes over the past 1 and 3 months before presentation should be made as part of the patient’s history. We define weight stability as no more than an average of 5 lb/month loss over 3 months. A patient still undergoing significant weight loss may be in a state of protein-calorie deficiency and consequently may be at risk of suboptimal wound healing. Those deemed not stable are delayed and reevaluated in 3 months. An overview of our timing of surgical planning is provided in Box 2 .
2-3 months before surgery
Initial evaluation
Weight loss history, evaluation of BMI (maximum, current, and change)
Medical and surgical history
Evaluation of medical comorbidities
Social history evaluation
Nutritional analysis
Psychological evaluation
Physical examination
Delineation of patient goals and management of expectations
Photographs are taken
Follow-up visit 2-3 mo if further weight loss/weight stability is needed
1 month before surgery
Formal preoperative visit
Surgical plan reviewed
Questions answered
Informed consent obtained
Preoperative laboratory blood specimens are drawn
Preoperative medical evaluations should be performed as necessary
2 weeks before surgery
Antiplatelet medicines (e.g. aspirin, NSAIDs) are discontinued
Laboratory tests and medical clearances are reviewed
Nutrition is optimized
Day before surgery
Light bowel preparation (1/2 bottle of magnesium citrate at noon, followed by clear liquids) is administered for all abdominal procedures
Transportation in confirmed
Surgical plan and photographs are reviewed by the surgical team
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