Body Contouring Surgery Following Massive Weight Loss
FEATURE Body contouring surgery following massive weight loss
BY GARY L ROSS
here are many different that they would qualify for bariatric brings with it many health benefits perceptions about what (weight loss) surgery under current and improves both self-esteem and defines the term ‘overweight’. National Institute for Health and Care quality of life, it has the downside of T The reality is however that, for Excellence (NICE) guidelines. leaving patients with large quantities many, being overweight is a condition With increasingly reliable and safe of loose hanging skin, which can cause that brings with it significant health bariatric procedures, the number considerable distress. This article and social problems. It is estimated of bariatric surgical operations has focuses on the role of plastic surgery that almost two thirds of all adults increased dramatically over the last in the management of patients who in the UK are either overweight or 10 years and these operations have have lost significant amounts of weight obese and that there are more than become established in mainstream either through bariatric surgery or two million adults in England with National Health Service (NHS) non-surgical weight loss. a body mass index (BMI) so high practice. Although bariatric surgery It is often impossible to predict
Figure 1 (pre and postoperative): Often following weight loss the volume and shape of the breast changes, making the nipple sit lower than the aesthetic ideal. Using a one-stage mastopexy implant a good result can be achieved. This result is taken at four months postoperatively and the scars have settled down well. This is often the best option for breast rejuvenation following weight loss surgery.
Figure 2 (pre and postoperative): Liposuction only is uncommonly required following weight loss surgery unless there are specific areas of fat that are resistant. In this case liposuction has been performed on the trunk and flanks and hips to improve contour. It requires good skin elasticity to give optimal results.
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Figure 3 and 4 (pre and postoperative): This lady has had an extended arm lift to remove excess tissue in the upper arms, armpit and the sides of the chest. The scars are placed in such a way that they are difficult to visualise. Often following weight loss this is the best treatment for patients wishing to have arm rejuvenation.
which patients will develop excess they once were but also results in both with risks and all potential skin as a result of losing weight. functional and aesthetic concerns. co-morbidities should be optimised Concerns about the final appearance The decision to proceed with weight prior to any surgery. Smoking is after dramatic weight loss may loss surgery should only be made after almost always a contraindication discourage patients wishing to the patient has been fully informed for weight loss surgery and where tackle their obesity, even though the about the pros and cons of surgical comorbidities can be optimised prior to distribution of excess skin around the treatment by a multidisciplinary team surgery it is important that these body may be minimal and patients may (MDT) which carefully assesses the are addressed first. be happy with the resultant appearance patient’s fitness, preparedness and Patients are strongly encouraged and require no further surgery. expectations of surgery. Within the to consult with their GP not only for However, more often, especially in UK there are a number of dedicated advice on appropriate referral but also to keep them informed of what is a moderate to severe cases, the excess bariatric MDTs within both the NHS significant interventional procedure tissue is not only a reminder of the size and the independent sector, who provide on-going support for those who with potential implications on both undergo body contouring surgery, for health and disease. example, Phoenix Health have weight loss clinics throughout the UK and The consultation and Ireland. choosing a surgeon / provider When it comes to considering body When a patient looks for a plastic “Success is influenced contouring surgery, weight stability surgeon regarding post-bariatric and a near-normal BMI are two of the correction it is important to find not by the patient’s age, most important aspects to consider. only a surgeon but also a team that and also the size, shape Patients should be close to their ideal inspires confidence, trust and a sense weight and be weight stable for at least of comfort. The team should include and skin tone of the a year prior to considering excision of specialists who can advise on every excess skin or post bariatric weight loss aspect of weight loss including nutrition area to be treated.” surgery. Any surgical procedure comes and exercise as well as the technical
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Figure 5 (pre and postoperative): This lady has previously had laparoscopic weight loss surgery. The tummy button has been relocated in one of the previous scars following laparoscopy and the excess tissue has been removed. This has resulted in improved definition of the abdomen.
Figure 6 (pre and postoperative): This lady had extensive fat in the upper abdomen and a previous incision in the midline. In this scenario a fleur de lis abdominoplasty can help address this upper fullness and improve the abdominal contour. This is a picture taken after three months and the vertical scar will continue to fade over time. Occasionally this may be required following weight loss surgery. details of the body contouring surgery. surgical team that can provide 24/7 pubic region and relocating of the It is important that patients are honest cover for the patients. It is a good idea umbilicus (abdominoplasty) and both with themselves and with their to arrange for a pre-admission visit to total body lifting (removal of tissue surgeon and they must be prepared to the hospital so that patients can feel circumferentially around the body). undergo psychological screening which confident and comfortable that they will For weight loss surgery the pros and may require further assessment. Some be in a welcoming and safe environment. cons of abdominoplasty, body lifting surgeons will show preoperative and and fleur de lis abdominoplasty need postoperative images with the caveat What can be achieved? to be carefully considered. A standard that these are just a guide and not a Lack of tissue elasticity results in abdominoplasty and apronectomy predication and most surgeons should sagging skin that commonly develops requires a horizontal scar above the be able to organise informal meetings around the face, neck, upper arms, pubis, a fleur de lis abdominoplasty with ‘satisfied customers’. Consultations breast, abdomen, buttocks and thighs requires the same horizontal scar and for post bariatric surgery are often which can make the body contour a vertical midline scar and a body lift lengthy but it is an important part of the appear irregular. Body contouring requires a circumferential horizontal informed consent process that the risks surgery can reduce the excess skin scar at waist level. Arm lifting and thigh and benefits and what can realistically and fat that is left behind after a major lifting are also commonly performed to be achieved are fully explained but also weight loss in any of these areas and remove excess tissue. Scars in arm lifts fully understood. This may take several improve contour. often extend from the elbow, into the consultations. armpit and down the chest wall. Scars All established surgeons should What areas can be addressed? for thigh lifts can be placed in the groin be able to provide outcome data and Generally the abdomen is the / buttock crease but often skin excess is numbers of procedures they have commonest area that patients wish distributed all the way around the thighs performed together with complication to have addressed. Options involve and it is necessary to place a scar from rates. In terms of the extended team removal of overhanging tissue only the groin in a vertical nature down to there should be a physiotherapist, without relocation of the umbilicus the knee. Scars can be placed below the dietician, provision of intensive care (appronectomy), removal of excess knee or elbow but this is generally the on site, dedicated nursing staff and a tissue via an incision above the limit of the extent of scar placement as
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Figure 7 (pre and postoperative): A body lift involves the removal of tissue all the way around the body. It is truly the only way to address the excess tissue around the flanks and buttocks following weight loss surgery. Although a more extensive procedure for patients presenting in this manner, a body lift is the best rejuvenating technique.
scars over joints can limit mobility and for excessive skin excess include total within four weeks due to the increased are not recommended. body lifting / arm lift and thigh / breast risks of DVT. All patients are offered For sagging breasts, mastopexy and lift. For women with moderate weight open appointments to return at any implant insertion is the most common loss the commonest combination is point following surgery. procedure and is usually performed breast lift / mastopexy implant and in one stage. Alternatively implant adbominoplasty. It is important to keep What are the risks? insertion alone or mastopexy alone may the operative time to a minimum and The complications of body be performed. where time in theatre can be reduced to contouring following weight loss Other areas may need to be less than four hours one can avoid the surgery must not be underestimated addressed, especially the upper part need for a catheter and can decrease although careful patient selection, of the abdomen, the back and flanks. the risks of deep vein thrombosis (DVT) preoperative optimisation and efficient Furthermore, in excessive weight loss and other postoperative complications. postoperative care can limit these the lower abdomen may need to be This makes mobilisation easier and in complications. addressed in two stages. my practice I encourage patients to The success is influenced by the Liposuction is often performed mobilise as soon as possible following patient’s age, and also the size, shape alongside removal of excess skin. surgery. and skin tone of the area to be treated. One common misconception is that Some contouring procedures leave liposuction alone can improve the What should happen only small, inconspicuous scars but appearance and contour following postoperatively? more often than not more noticeable weight loss. Although this is Postoperatively patients should be scars are necessary to achieve a desired occasionally possible, liposuction mobilised as soon as possible and often result. Most patients find these scars is best performed on patients with patients will be placed in compression acceptable and enjoy greater self- isolated fat deposits with good quality garments. I personally do not like to confidence. The scars do start off red skin. This is rarely the case with use any dressings or drains so that and it takes a number of months for patients who have excess skin following patients can mobilise in the immediate the scars to settle. All patients are weight loss and liposuction in these postoperative period. The majority encouraged to massage the scars situations can make the appearance of patients are able to be discharged once the wounds have healed which worse if not combined with skin the day following surgery. All patients helps the scars become pale and excision. are given contact details and a softer. Massage also helps manage Body contouring surgery must be postoperative appointment – usually the local tissue swelling which always tailored to the patient’s individual the week after. I usually advise to keep occurs following surgery. This can needs and requirements, and the wound dry for a week and to avoid take from weeks to months to settle treatments must be individualised driving until followed up in the dressing following surgery. Pain is almost always accordingly. In certain circumstances clinic. I would usually advise taking one inevitable following surgery and this a combination of operations can be to two weeks off work following any varies between patients. Generally the performed. Common combinations surgery and would discourage flying most uncomfortable part of any body
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Figure 8 (pre and postoperative): For those with excess tissue all the way round the body that do not wish to undergo a total body lift an extended abdominoplasty can help to rejuvenate the abdomen. It will not address the excess around the flanks and buttocks but can give a dramatic improvement for weight loss patients.
contouring surgery is tightening of If this does occur it can take weeks the muscles of the abdomen which is to months to heal depending on the Gary L Ross, often necessary in abdominoplasty and extent. It is imperative that surgeons MBChB, MD, FRCS(plast), body lifting procedures. Sensation does with appropriate experience perform Consultant Plastic Surgeon, change following weight loss surgery. this surgery and patients are realistic MI Alexandra Hospital; Although most sensation returns there about what can be achieved. It is much Honorary Senior Lecturer are no guarantees that this will be the easier to revise or remove extra skin at University of Manchester, Manchester, UK. case and occasionally there are areas a second stage than treat a dehisced Correspondence: Gary Ross, where sensation does not fully recover. wound. Declaration of Department of Plastic Surgery, With all surgery there are risks of competing interests: BMI Alexandra, Mill Lane, bleeding and infection and especially None declared. Cheadle SK8 2PX, UK. in weight loss surgery there are risks Tel: +44 (0)845 468 8446 E: [email protected] of the build-up of serous fluid called www.garylross.com seroma. Occasionally patients may Acknowledgement: have to return to theatre, although Mr Ross would like to this is uncommon. For all weight acknowledge Phoenix Health www.phoenix-health.co.uk loss surgery there are risks of the wounds breaking down or dehiscing.
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