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The Changing Body After Bariatric Surgery – Plastic Surgery & Other

Options

Al Aly, MD, FACSProfessor of Plastic Surgery

Director of Aesthetic Plastic Surgery

University of California Irvine

Overview

� Why I specialize in MWL Plastic Surgery

� Educate you about “Body Contouring after Massive Weight Loss”

� Questions and Answers

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I have been doing MWL Plastic Surgery longer than

anybody in the world

How can that be?

A Little History

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Bariatric Surgery was fathered at the University of

Iowa back in the 60s and 70s

by a Dr. Mason

But it was not popular because of lack of refinement till 2000

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The field of body contouring after massive weight loss did not exist

then

A few places had MWL patients and Iowa was one

of them

Because of Mason

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When I started my practice at the University of Iowa there was a back log of

MWLPs

Forced by patient demand

Invented or Developed plastic surgery procedures utilized world wide today

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Dr. Aly published the first textbook

ever written on

the subject

“The BIBLE”

It has been sold or illegally copied all over

the world

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List of countries where I lectured and/or operated

� US (extensively)� Canada� Costa Rica� Brazil� Argentina� Mexico� Colombia� Dubai� Qatar� New Zealand

� Saudi Arabia� Germany� Spain� Turkey� Portugal� Russia� Kuwait� Egypt� Belgium� India� Australia

I am passionateand

I care very much

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What happens with weight loss after obesity?

The skin acts like a balloon, it expands

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When people lose weightSome patient’s balloon returns

to normal size

What happens when you gain weight then lose it?

Some patients’ skin expands past its limits and loses its elasticity

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They end up with Loose

excessive skin

Most MWLP will not go back to normal after

their weight loss

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Presentation of the MWLP is extremely variable

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If all treated the same wayResults are inferior

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Factors That Affect RESULTS

�Weight or BMI at presentation

�Fat deposition pattern

�Quality of skin-fat envelope

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Apple Pear

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Mind-Set at Presentation

Dear Dr,I use to weight 350 pounds and felt extremely bad about it, my health was awful, I could hardly get around. . . I had gastric bypass surgery 2 years ago and lost 200 pounds. . . Unfortunately, I still look and feel fat. I have worked so hard to get to where I am but I feel that it might have been all for nothing. Can you help me?

I still look and feel

fat

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Four Major Regions

�Lower trunk

�Upper arms

�Thorax

�Thighs

Massive weight loss patients have

circumferential lower truncal excess in the shape

of an inverted cone

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The Inverted Cone

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Treatment Options

�“T” shaped lipectomy

�Abdominoplasty

�Circumferential lipectomy

T Shaped Panniculectomy

May lead to bizarre contours

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T Shaped Panniculectomy

Even when done well has no effect on the sides or back

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� PostOp: False

� Age: 39

� PostOp: False

� Age: 39

No back or buttocks improvements

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Tummy Tuck

�Ideally treats�Mild excess belly fat

�Excess belly skin

�Belly laxity

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Bulge or “Dog Ear”

Tummy Tuck only in a massive weight loss patient

No back or buttocks improvements

Tummy Tuck only in a massive weight loss patient

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Bulge or “Dog Ear”

Tummy Tuck only in a massive weight loss patient

No back or buttocks improvements

Tummy Tuck only

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Rehabilitation of the lower trunk in the

massive weight loss patient most often

requires circumferential treatment

A Tummy Tuck is like a conventional weaponA BELT LIPECTOMY

is like a NUCLEAR WEAPON

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= TensionTension=Improvement

Tension =

Improvementaway from closure

=Improvement

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0 Tension

No back or buttocks skin tightening

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Why Circumferential?

� Eliminates� Pubic area excess

� Tummy bulges and aprons

� Outer and lower back excess

� Buttocks droopiness

� Lifts the outer and front thighs

� Increases buttocks definition

� Creates a waist

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Pubic Area

Abdomen

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Outer & Lower back

Waist

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Buttocks

Buttocks

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Front & Outer Thighs

Belt lipectomyLower body liftCentral body lift

Circumferential abdominoplastyTorsoplasty

BODY LIFT

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Body Lifts Are Not All The Same

Approaches to The Trunk

Lower Body Lift

Belt Lipectomy

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Lower body lift = LowBelt lipectomy = high

Lower body lift = Low

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Belt lipectomy = high

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The cinching leads to “an illusion”of increased projection

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Criteria For Surgery

� Medically healthy

� Psychiatric stability

� Non-smoker

� Reduced intra-abdominal content

� Stable weight for ~3 to 6 months

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Heroic efforts to lose weight are counter productive

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Belt Lipectomy/Body lift

� PostOp: False

� Age: 48

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Belt Lipectomy

�3 to 6 hours

�Requires two turns in the OR

�Recovery- 3 to 6 weeks

�Should be approached as a “major life event”

Massive Weight Loss

�Generally, results correlate with the patient’s BMI at surgery

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High BMI

Expected Results

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Expected Results

Intermediate BMI

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Expected Results

Near ideal BMI

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Upper arm excess in the

MWLP

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� PostOp: False

� Age: 48

In massive weight loss patients the excess crosses the axilla (armpit), onto the lateral chest wall

Thus, upper arm reduction or Brachioplasty must account for that

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General Physical Presentations

�Upper Arms�The excess crosses the axilla

�The excess is the posterior axillary fold

�Different amounts of retained fat

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� PostOp: False

� Age: 40

The Posterior Axillary fold

Presentation

� If greatly deflated – ideal

� If significantly inflated – preliminary liposuction & staged excision

� If intermediate – decision has to be made with patient

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Brachioplasty in the MWLP SHOULD

CROSS THE AXILLA and follow the defect

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� PostOp: False

� Age: 40

The Double Ellipse Technique

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Brachioplasty Results

Why Doesn’t The Traditional “T”Approach Work

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� PostOp: False

� Age: 25

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Upper Arm Complications

� Seroma

� Lymphocele/lymphedema

� Inability to close the arm

� Bad scarring

� Infection/Bleeding

� Nerve compression/sensory loss

Upper Body Lifts treats

Entire Chest Deformity

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Thorax

The Normal Position

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The Normal Position

Thoracic Deformities

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General Physical Presentations

� Thorax-upper truncal subunit� An analogy - expansion and then

deflation of a lamp shade that is tethered at two points

� Horizontal excess – extension of the upper arm excess

� Vertical excess

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Upper Body Lift Results

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� PostOp: False

� Age: 22

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� PostOp: False

� Age: 24

� PostOp: False

� Age: 24

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� PostOp: False

� Age: 25

� PostOp: False

� Age: 25

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Thigh Reductions

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� PostOp: False

� Age: 25

� PostOp: False

� Age: 32

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Thigh Reduction in the MWLP

�Mostly a vertical excision

�Occasionally a horizontal component

�This approach follows the defect

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Insurance does not cover much past the hanging belly

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Consider working on finance EARLY

should you need it

Be realistic in your expectations

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Greater rate of complications

BEWARE &

BE AWARE

Body contouring after MWL is highly specialized

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Be a WISE CONSUMER when it comes to plastic

surgery after MWL

Summary

�Skin acts like a balloon

�Body lifts are required

�Body lifts are not all the same

�Arm reduction to chest wall

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Summary

�Upper body needs an UBL

�The thighs are hard

�Realistic expectations

�Higher rate of complications

Summary

�Insurance doesn’t cover

�So PLAN

�Be a wise consumer

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Plastic Surgery can be a

LIFE TRANSFORMATION

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I still look and feel

fat

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“Bariatric surgery gave me back my life, the plastic

surgery that I had allowed me to enjoy it”

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Al Aly, MD, FACS

End