Principles of Plastic Surgery After Massive Weight Loss

J. Peter Rubin

INTRODUCTION

Plastic surgery following massive weight loss (MWL) is a relatively new subspecialty of plastic surgery, fueled by the obesity epidemic and successful outcomes from bariatric surgery. MWL patients represent a unique cohort that differs from typical body contouring patients. Evaluation must take into account complex medical and psychosocial issues associated with obesity and operative planning requires unique strategies. The goal of this chapter is to provide a safe and comprehensive approach to management of the MWL patient. Technical details of specific operative procedures appear in Chapters 65, 66, 67 and 68. The key topics covered here are 1) the medical impact of obesity and the rise of bariatric surgery as an effective therapy, 2) critical factors for consideration in the preoperative evaluation of the MWL patient presenting for plastic surgery, and 3) a framework for designing a safe operative plan, including when to combine multiple procedures and when to perform them in separate stages.

OBESITY, ASSOCIATED MEDICAL COMORBIDITIES, AND IMPACT OF BARIATRIC SURGERY

Obesity has a major impact on the health of our patients, and an appreciation for the medical problems associated with overweight and obese patients is vital. The key metric, body mass index (BMI), obtained by dividing weight in kilograms by height in meters squared (kg/m2), is used to define “overweight” as a BMI of 25.0 to 29.9 kg/m,2 obesity as a BMI > 30 kg/m2, severe obesity as a BMI > 35 kg/m2, and morbid obesity as a BMI > 40 kg/m2. Obesity rates in the United States, based on 2010 Centers for Disease Control data, reveal that no state has a prevalence of obesity less than 20%. In contrast, 1995 data indicated not a single US state had an obesity prevalence rate exceeding 20%.1 A striking statistic is that 33.8% of adults over age 20 are classified as obese, and nearly 5% are morbidly obese with a BMI > 40 kg/m2.2 Worldwide, the International Obesity Task Force estimates that over 1 billion individuals are overweight and 475 million are obese.3

Medical comorbid conditions associated with obesity are numerous. Diabetes, hyperlipidemia, hypertension, obstructive sleep apnea (OSA), gastroesophageal reflux disease, and osteoarthritis are common. These conditions are all greatly improved by weight loss, but may still be present at the time of plastic surgery consultation and are specifically considered and addressed.

The most effective treatment for morbid obesity is bariatric surgery, and a 1991 National Institutes of Health Consensus Conference recommended the procedure for patients with a BMI > 40 kg/m2 or a BMI > 35 kg/m2 with significant comorbid conditions.4

Since that time, rates of bariatric procedures performed have increased steadily, with over 200,000 people undergoing various weight loss procedures annually. The improvement of obesity-related medical disorders following bariatric surgery has been a major health benefit.5^,6

Deflation of the skin envelope after successful weight loss results in a varied constellation of deformities in many bariatric surgery patients. Nearly every region of the body can be affected, resulting in redundant, loose, hanging rolls of skin and fat often in patterns that had not previously been described in the plastic surgery literature.7 These deformities lead to intertriginous rashes, chronic fungal infections, skin breakdown, soft tissue sepsis, and social embarrassment. Patients frequently seek consultation with a plastic surgeon to address these deformities, and often consider body contouring as the “final phase of their weight loss journey.” With the increased number of bariatric procedures, body contouring has been a tremendous area of growth in plastic surgery, and many plastic surgeons are now exposed to the weight loss population in their training and practices.8

PREOPERATIVE EVALUATION

The surgeon must bear in mind that these are truly elective cases on complex patients and deferring surgery to modify risk factors is never a bad option. Indeed, in the Life After Weight Loss post-bariatric center at the University of Pittsburgh, patients are often engaged in a collaborative effort to further reduce BMI or improve nutritional status over a period of many months before surgery is offered.9

We have identified six key assessment points in a comprehensive preoperative evaluation of the MWL patient: 1) timing of body contouring surgery relative to gastric bypass; 2) BMI at presentation; 3) nutritional assessment; 4) evaluation for medical comorbidities of obesity; 5) evaluation of psychosocial issues, and 6) assessment of the physical deformities. Table 69.1 outlines pitfalls at each step, along with pitfalls in operative planning and management.

The surgeon and office staff must recognize that an MWL patient has made a major life transformation through great dedication and should be congratulated on this accomplishment. Importantly, since these patients are constantly struggling with self-esteem issues, appropriate compassion helps them feel more comfortable.

Weight Loss History and Timing of Plastic Surgery Relative to Bariatric Surgery

A history of the age of onset of obesity, family history of obesity, and course of obesity over the patient’s life leading up to bariatric surgery is obtained. A detailed history of the type of bariatric procedure performed includes the type of procedure, date of procedure, any complications and/or additional procedures, and course of weight loss since the procedure. An accurate weight is obtained in the office, and inquiry made about goal weight. The highest BMI prior to bariatric surgery, the lowest BMI since bariatric surgery, and the BMI at the time of presentation are calculated and recorded. Additionally, we find it helpful to document weight loss over the previous month and 3 months prior to presentation. We require weight stability, defined by not more than 5 lb of weight change per month in the previous 3 months.

Timing of plastic surgery following MWL is an important factor and patients must be at a stable weight before undergoing body contouring. Patients typically experience a significant and rapid weight loss during the first year after bariatric surgery. In general, a minimum of 12 months
should elapse following weight loss surgery to enable the patient to reach this plateau, and often a plateau is not observed until 18 months post-op. A patient still undergoing rapid weight loss may not have achieved metabolic and nutritional homeostasis and could be at risk for suboptimal wound healing. Protein intake is usually improved for patients after 12 months following bariatric surgery. In addition, the aesthetic results may be compromised if a patient loses a significant amount of weight after body contouring surgery. Patients still actively losing weight are deferred and reassessed in 3 months.10

TABLE 69.1 KEY STEPS IN EVALUATION AND MANAGEMENT, AND POTENTIAL PITFALLS

▪	KEY STEP IN EVALUATION AND MANAGEMENT	▪	PITFALLS
	Timing of body contouring surgery relative to GBP		Patients less than 12 months from GBP may still be actively losing weight and in a catabolic state
	BMI at presentation		High BMI can impact patient safety and aesthetic outcomes; attempts should be made to optimize BMI before body contouring surgery
	Nutritional assessment		Oral protein intake often low in post-GBP patients. Low serum protein measures cannot be ruled out by history alone. Iron deficiency and associated anemia is common in the GBP population
	Evaluation for residual medical comorbidities of obesity		Unrecognized cardiac disease may be exacerbated by stress of body contouring surgery
	Evaluation of psychosocial issues		Low self-esteem is a persistent issue faced by weight loss patients and can affect satisfaction. Additionally, body dysmorphic disorder and other body image issues can be found even in patients with significant deformities
	Evaluation of anatomic deformities		Suggesting operations based on apparent severity deformities present, rather than first asking the patient to prioritize areas of concern, can result in an operative plan that is not well tailored to the patient’s goals
	Planning operative procedure		Patient desire for correction of multiple body regions can lead to an overly aggressive operative plan, given such factors as surgical setting and composition of OR team
	Postoperative management		Patients may not be fully aware of the magnitude of recovery from major body contouring procedures and high incidence of wound healing problems
GBP, gastric bypass; BMI, body mass index; OR, operating room.

Role of BMI

Once weight stability is verified, BMI at presentation is carefully considered. There is no absolute threshold for BMI prior to surgery, but the best candidates for extensive body contouring surgery typically have a BMI less than 30 kg/m2 and can be considered for a wide range of procedures including multiple procedures, if their medical and psychological conditions are favorable.12 While a BMI lower than 25 kg/m2 is optimal, that value is not commonly seen after MWL and many successful bariatric patients will present in the BMI range of 25 to 30 kg/m2. At higher BMIs between 30 and 35 kg/m2, one must be more selective and evaluate individual patterns of body fat distribution to guide surgical planning. For example, a patient with an android body type might have a large intra-abdominal adipose burden at a BMI of 35 kg/m2 that limits effective abdominal contouring. Patients with a BMI between 35 and 40 kg/m2 tend to have findings that limit effective aesthetic contouring, including a thicker subcutaneous adipose layer and a large intra-abdominal fat compartment. In this patient group, we focus on single procedure, functional operations to relieve symptoms and encourage further weight loss. An initial panniculectomy or reduction mammaplasty can greatly improve comfort and ability to exercise as the patient strives for further weight loss. Surgery is usually deferred for patients with a BMI > 40 kg/m2 until they achieve further weight loss, unless symptoms are unusually severe (e.g., acute or recurrent soft tissue sepsis on the pannus).

When a patient with a higher than optimal BMI is encountered, the surgeon should consider deferring surgery and referring the patient back to the bariatric surgeon and/or nutritionist for further weight loss. Follow-up visits with the plastic surgeon at 3-month intervals will keep the patients engaged and motivated toward their goals of being good candidates for body contouring surgery.

Regarding risk and BMI, a prospective analysis of 511 postbariatric cases at our center demonstrated that both higher pre-bariatric maximum BMI and BMI at presentation were associated with increased complications in patients undergoing a single body contouring procedure. The same study found that the change in BMI (maximum to BMI at presentation) was directly related to overall complications in patients undergoing multiple procedures.11 These BMI parameters and their association with complications have been corroborated by other investigations.12 Others have found that the frequency of both major and minor complications were higher in the morbidly obese and severely morbidly obese groups.13

Search for Residual Medical Comorbidities

Weight loss induced by bariatric surgery improves health and alleviates active disease, with effects noted often within the first 2 to 5 months postoperatively.14 It is gratifying to hear patients talk about going from handful of medications to barely any prescription drugs. However, the plastic surgeon must actively inquire about the most common comorbidities
of obesity and search for unresolved issues. While Pories et al.15 demonstrated that 82% of obese patients with type II diabetes mellitus had resolution of their disease following weight loss, patients with persistent insulin resistance will still present to the plastic surgeon. Hemoglobin A1C is checked as an indicator of glucose control. Oral hypoglycemic agents are held on the morning of surgery, and insulin dose, if applicable, is reduced on the morning of surgery consistent with the fasting state. For all diabetic patients, glucose is monitored every 6 hours postoperatively and treated with an insulin sliding scale for tight glycemic control. The plastic surgeon may opt for assistance from an internist in the management of these issues but the ultimate responsibility is his/hers and the surgeon should be familiar with the dose of every medication given to his/her patient.

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