body contouring

Body Contouring and massive weight loss in the NHS

48yo man MWL 200-100kgs diet and exercise only

Presents to outpatients requesting information on Body Contouring Surgery

Highly motivated professional with no significant past medical history

• May 2009 following PCT approval and adequate counseling underwent– Lower body lift

• 9.9kgs of subcutaneous tissue excised

• 4 hour 2 surgeon approach• Patient re-positioned 3

times• X6 drains• Intra-operatively required

6units of PC • Otherwise unremarkable

Post-op

• Day 1:– BP 80/40 HR 110, 1 drain >1L over 2 hours– Immediate exploration and evacuation of 3L haematoma with no

bleeding source identified• Day 1:

– 12 hours after first exploration– BP undetectable, ABG Hb 4, aggressive resuscitation and re-

explored– Minor bleeds cauterised but nil identifiable source – Evacuation of 2.2L haematoma

• Short stay in ICU but following 32 units of PC discharged day 8

Outpatients

• Weekly drainage of seroma collections • Extremely happy!!!• Can’t wait to get the next stage of his BC

performed

The Obesity Epidemic

• Derived from the Latin word obesus – “to devour”

• Obesity is growing at an alarming rate in both children and adults in Westernized countries

International Union of Nutritional Sciences. The global challenge of obesity and the International Obesity Task Force:2002

The Obesity Epidemic• According to recent data, the number of annual deaths attributed to obesity (in the United States) is

estimated to be 112,000. International Union of Nutritional Sciences. The global challenge of obesity and the International Obesity Task Force: Tables. Available at http://www.iuns.org/features/obesity/ tabfig.htm#Table%201. Accessed on September 6, 2005.

• Although this number is lower than the earlier estimate of 300,000 deaths, Ogden, C. L., Flegal, K. M., Carroll, M. D., and Johnson, C. L. Prevalence and trends in overweight among U.S. children and adolescents. J.A.M.A. 288: 1728, 2002.

• Morbidities associated with obesity, including:– diabetes, – heart disease, – some cancers, – and arthritis,

• Reduce a patient’s quality of life and contribute to escalating medical costs.

Prevalence of obesity, diabetes, and obesity related health risk factors. Mokdad, A. H., Ford, E., Bowman, B. A., et al. J.A.M.A. 289: 76, 2001

• A weight gain of 11 to 18 pounds increases a person’s risk of developing type 2 diabetes to twice that of individuals who have not gained weight

• >80% of people with diabetes are overweight or obese• Incidence of heart disease is increased in persons who

are overweight• High blood pressure is twice as common in adults who

are obese than in those who are at a healthy weight• For every 2-pound increase in weight, the risk of

developing arthritis is increased by 9 to 13%

Bariatric surgery: A systematic review and meta-analysis. Buchwald, H., Avidor, Y., Braunnald, E., et al. J.A.M.A. 292: 1724,

2004

• Comprehensive review and meta-analysis analyzed 136 bariatric surgery reports.

• This study reviewed 22,094 patients with a mean age of 39 years (range, 16 to 64 years)

• Average body mass index of 46.9 (range, 32.3 to 68.8).

• The group was 72.6% female and 27.4% male.

Bariatric surgery: A systematic review and meta-analysis. Buchwald, H., Avidor, Y., Braunnald, E., et al. J.A.M.A. 292: 1724,

2004

• The authors concluded that co-morbidities were improved by bariatric surgery– Lipid disorders improved in 70% of patients.– Diabetes improved in 76.8% of patients.– Hypertension improved in 78.5% of patients.– Obstructive sleep apnea improved in 85.7% of patients.

• The positive physical improvements that often accompany weight loss, as well as the increase in self-esteem, can equate to an improved quality of life for these patient

• American Society for Bariatric Surgery, its member surgeons performed:– 28,800 weight loss operations in 1999– 63,000 weight-loss operations in 2002, – 140,000 weight-loss operations in 2004

• Mayo Foundation for Medical Education and Research. Gastric bypass: Is this weight-loss surgery for you?

• American Society of Plastic Surgeons, nearly 56,000 body contouring procedures were performed for massive weight loss patients in 2004

• The increased safety and effectiveness of bariatric surgery give plastic surgeons additional opportunities to refine body contouring

Bariatric Surgery Procedures

• Bariatric surgery is currently the only therapy effective at achieving weight loss with significant improvement or resolution of co-morbidities– Buchwald, H., Avidor, Y., Braunnald, E.,

et al. Bariatric surgery: A systematic review and meta-analysis. J.A.M.A. 292: 1724, 200

Bariatric Surgery Procedures• Bariatric procedures are

typically classified as:– Purely restrictive

• Gastric adjustable banding• Vertical-banded gastroplasty• Gastric balloons

– Restrictive > malabsorptive• Short-limb/Roux-en-Y gastric

bypass

– Malabsorptive > restrictive• Biliopancreatic diversion• Very long limb Roux-en-Y gastric

bypass

– Purely malabsorptive• Jejunoileal bypass• Jejunocolonic bypass

Implications of Weight Loss Method in Body Contouring Outcomes

Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D. Plast. Reconstr. Surg. 123: 373, 2009

• 499 patients (511 cases) were entered into a prospective registry.

• Diet and exercise patients were matched to bariatric patients based on identical procedures performed

• All patients with a weight loss of greater than 50 lb were included

• 477 cases (93.3 percent) had bariatric procedures • 29 patients representing 34 cases (6.7 percent) lost

weight exclusively through diet and exercise

Implications of Weight Loss Method in Body Contouring Outcomes

Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D. Plast. Reconstr. Surg. 123: 373, 2009

• Conclusion, that diet and exercise had:– higher absolute complication rates, – significantly higher infection rates (p = 0.03). – When matched to 191 bariatric patients based on

procedures performed, had a higher complication rate that did not reach significance (odds ratio, 1.5; p =0.28)

– One-to-one matching resulted in 34 procedure-matched pairs with non-significant trends toward:• better nutrition and albumin • more complications

• Conclusion, that diet and exercise had:– higher absolute complication rates, – significantly higher infection rates (p = 0.03). – When matched to 191 bariatric patients based on

procedures performed, had a higher complication rate that did not reach significance (odds ratio, 1.5; p =0.28)

– One-to-one matching resulted in 34 procedure-matched pairs with non-significant trends toward:• better nutrition and albumin • more complications

Potential Impacts of Nutritional Deficiency of Postbariatric Patients on Body Contouring Surgery

Siamak Agha-Mohammadi, M.B., B.Chir., Ph.D. Dennis J. Hurwitz, M.D. Plast. Reconstr. Surg. 122: 1901, 2008

• Protein-Calorie Malnutrition– 25% of weight loss surgery patients are at risk of developing

protein-calorie malnutrition– Protein deficiency impairs wound healing because protein is

needed for:• fibroblast proliferation• angiogenesis• collagen production • oedema adversely affects perfusion of the healing tissues

– severe protein-calorie malnutrition associated with immunosuppression which in turn correlates clinically with increased wound complication rates

Vitamin B6, Vitamin B12, and Folate Deficiencies

• Folate deficiency has an incidence of 9-35% after bypass operations.

• vitamin B6 deficiency is approximately 17.6 %• vitamin B12 deficiency ranges from 3.6-37% at 1 year

after Roux-en-Y gastric bypass• Folate and vitamin B12 are required for the formation of

S-adenosylmethionine, which is critical for stabilization of DNA and many proteins – Thus, deficiencies of these vitamins can potentially

contribute to poor cellular proliferation and repair in the post-bariatric body contouring

Thiamine

• Deficiencies of thiamine likely to be subclinical.

• Thiamine plays an essential role in the metabolism of carbohydrates and branched-chain amino acids – thus may have an important role in the healing

process.

Vitamin C Deficiency

• Incidence of vitamin C deficiency in Roux- en-Y gastric bypass patients is:– 34.6% at the 1 Year– 35.4% - and 2-year

• Plays an important role in wound healing by:– Increasing collagen synthesis– Angiogenesis– associated with capillary leakage caused by decreased

collagen production and susceptibility to wound infections

Vitamin A Deficiency

• up to 69% of post-bariatric patients 4 years after surgery

• Vitamin A is an essential factor in the healing patient, as it functions as an:– Immunostimulant, – Enhancing inflammation-driven wound healing

Vitamin E

• Vitamin E plays an important role in supporting monocyte/macrophage-mediated responses

• Also excess supplementation can inhibit collagen synthesis and decrease tensile strength of wounds because vitamin E has anti-inflammatory properties similar to steroids .

Iron Deficiency

• 30-50% with all types of bariatric surgery • May present with microcytic anemia• Post-bariatric body contouring patients can lose a

significant amount of blood during surgical procedures, it is important that the patient’s haemoglobin and haematocrit are optimized in the preoperative setting.

• Severe iron deficiency can impair collagen production and increase the risk of opportunistic infections

Zinc Deficiency

• Deficiency is demonstrated in 36% of post-bariatric patients despite vitamin supplementation

• Zinc-deficient subjects are at risk of decreased :– fibroblast proliferation– collagen synthesis,

• leading to decreased wound strength and delayed epithelization

• Has role in supporting the both the humeral and cellular immune system. – resulting in an increased susceptibility to wound infection

and the possibility of delayed healing

Charing Cross Experience

• Currently bariatric surgery is funded by PCT with hundreds of procedures performed yearly

• Body contouring surgery not yet funded by PCT

• Therefore, scores of eligible patients who will miss out on BC surgery

When to operate?• Minimum 12 months after gastric

banding/bypass surgery• 3 months of stable body weight• BMI <30• When possible stage the body contouring

procedures.– Atleast 3 months between BC procedures

procedures

Implications of Weight Loss Method in Body Contouring Outcomes

Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D. Plast. Reconstr. Surg. 123: 373, 2009

• 499 patients (511 cases) were entered into a prospective registry.

• Diet and exercise patients were matched to bariatric patients based on identical procedures performed

• All patients with a weight loss of greater than 50 lb were included

• 477 cases (93.3 percent) had bariatric procedures • 29 patients representing 34 cases (6.7 percent) lost

weight exclusively through diet and exercise

Implications of Weight Loss Method in Body Contouring Outcomes

Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D. Plast. Reconstr. Surg. 123: 373, 2009

• Conclusion, that diet and exercise had:– higher absolute complication rates, – significantly higher infection rates (p = 0.03). – One-to-one matching resulted in 34 procedure-

matched pairs with non-significant trends toward:• better nutrition and albumin • more complications

• Conclusion, that diet and exercise had:– higher absolute complication rates, – significantly higher infection rates (p = 0.03). – One-to-one matching resulted in 34 procedure-

matched pairs with non-significant trends toward:• better nutrition and albumin • more complications

Potential Impacts of Nutritional Deficiency of Postbariatric Patients on Body Contouring Surgery

Siamak Agha-Mohammadi, M.B., B.Chir., Ph.D. Dennis J. Hurwitz, M.D. Plast. Reconstr. Surg. 122: 1901, 2008

• Protein-Calorie Malnutrition– 25% of weight loss surgery patients are at risk of

developing protein-calorie malnutrition– Protein deficiency impairs wound healing because

protein is needed for:• fibroblast proliferation• angiogenesis• collagen production • oedema adversely affects perfusion of the healing tissues

• Iron deficiency anaemia in 30-50% with all types of bariatric surgery

Potential Impacts of Nutritional Deficiency of Postbariatric Patients on Body Contouring Surgery

Siamak Agha-Mohammadi, M.B., B.Chir., Ph.D. Dennis J. Hurwitz, M.D. Plast. Reconstr. Surg. 122: 1901, 2008

• Folate deficiency has an incidence of 9-35% after bypass operations.

• Vitamin B6 deficiency is approximately 17.6 %• Vitamin B12 deficiency ranges from 3.6-37% at

1 year after Roux-en-Y gastric bypass• Incidence of vitamin C deficiency in Roux- en-Y

gastric bypass patients is 34.6% at the 1 Year• Vitamin A deficiency up to 69% of post-bariatric

patients 4 years after surgery

Key Points for Review with the Massive Weight Loss Patient

• Length of body contouring procedures• Need for multiple/staged procedures to achieve

optimal result– Ability to go back and revise as needed

• Increased risk in smokers• Scars:– Placement – Migration – Contracture – Asymmetry

Key Points for Review with the Massive Weight Loss Patient

• Recurrent skin laxity • Potential for sensory loss, especially in the arms • Inability to close the wound • Risk of deep vein thrombosis/pulmonary embolism• Potential for:

– Dehiscences – Seromas – Lymphocele/lymphedema

• Importance of weight maintenance • Possibility of:

– Sexual dysfunction – women Vulvar distortion

Preoperative Evaluation

• Body habitus/fat deposition patterns

• Morphology of skin redundancy

• Degree of skin deflation• Body mass index at

presentation• Quality of skin envelope• Scar placement

Deflation

-Tissue deflation is often, but not always, present in the massive weight loss patient. -Patients with a similar body mass index and total weight loss can present as:

-deflated,-mildly deflated, or -non- deflated (minimum loss of fat)

EVALUATING THE UPPER TRUNK

• Evaluation of the upper trunk should include a thorough analysis of the:– breast and chest – upper back.

EVALUATING THE THIGHS/LEGS• Determine the degree

of deflation and excess skin and the location and amount of excess fat.

EVALUATING THE FACE

• The face of the massive weight loss patient ages prematurely

• These patients tend to lose more volume in the mid-face, and their skin is more lax and less elastic

• Marked excess of laxity in the neck region

Surgical goals in lower body procedures

• Flattening the abdomen• Recreating the umbilicus• Elevating the mons• Creating a waist in female patients• Excision or liposuction of lower back rolls• Defining the buttocks• Lifting the outer/anterior thighs • Improving the inner thighs

Abdominoplasty (tummy tuck)

• Removes extra skin and fat from the navel to the pubic area

• Tightens muscles in the abdomen• Liposuction may be done during BC surgery

Dr Ted LockwoodHigh Lateral Tension suture

2001

• Classic approach improves contour by pulling inferiorly on the central abdomen, thereby creating the highest tension along the central incision, – HLT pulls obliquely from each of the incision's 2

lateral arms, thereby placing the highest tension laterally.

Panniculectomy• Removes a large apron of skin and fat that

hangs from the abdomen below the belly button

• No tightening of muscles, liposuction, or moving the belly button is done

Mons Reduction

• Rejuvenate the pubic area of the massive weight loss patient

Surgical goals in upper body procedures

• To reshape/augment breast parenchyma to restore projection and fullness

• To achieve appropriate nipple-areola complex position and size

• To recreate/reposition the inframammary fold• To reduce the skin envelope• To eliminate prominent axillary skin rolls• To elimination mid- and upper-back rolls

Breast Reshaping

• Asymmetrical volume loss in the massive weight loss breast,

• More of a deflated and flat appearance of the breast.

• Skin laxity is very apparent

Age: 37 Procedure: Mastopexy

Weight Lost: 75kgs after Lap-BAND 14 months post-BC

Age: 38 Procedure: mastopexy augmentation (implants)

Weight Lost: 60kgs after gastric bypass 24 months post-BC

Breast in Male Massive Weight Loss Patients

• Body mass index: before weight loss and current

• Degree of nipple-areola complex ptosis• Amount of breast projection• Amount of hypertrophy• Amount of excessive skin• Loss of inframammary fold definition

28-year-old man Procedure: mastopexy and liposuction of the chest

Weight loss: 30kgs

Arm lift (brachioplasty) • Removes excess skin that

hangs loosely from upper arms

• Liposuction may be needed before or during surgery to remove excess fat in upper arms

Age: 58 Procedure: brachioplasty

Lost: 45kgs after gastric bypass surgery 5 months post-BC Before

Age: 45 Procedures: Brachioplasty, axilloplasty, and mastopexy

Weight Lost: 60kgs after Roux-en-Y gastric bypass 4 months post-BC Before

Arm lift (brachioplasty)

Rhytidectomy (facelift) in the massive weight loss patient requires a multiplaner technique to adequately

address both volume deficiency and skin laxity