Contouring complicationsContouring complications

Key Points

Obese patients who undergo body contouring surgery following massive weight loss (MWL), resulting from either a gastric bypass surgery or through diet and exercise, can benefit greatly from body contouring surgery in terms of correction of functional and aesthetic deformities incurred by the obesity. Yet not all patients fare the same in terms of surgical outcomes, as complications such as wound healing and seroma formation may preclude the most favorable aesthetic results. A recent study probing the factors that influence optimal post-MWL surgical outcomes has shown that male gender, hypothyroidism and Ehlers-Danlos syndrome are three factors that negatively affect aesthetic outcomes in body contouring surgery. Michele A. Shermak, M.D., F.A.C.S., associate professor and chief of the Division of Plastic Surgery at Johns Hopkins Bayview Medical Center, Baltimore, Md., conducted a retrospective analysis of 139 patients (115 female, 24 male) who underwent body contouring surgery following MWL, and studied various outcome measures including seroma formation, wound dehiscence, thromboembolic complications, blood transfusion after surgery, and extended lengths of stay post-op (categorized as longer than two days).

OBJECTIVE OUTCOMES "Although techniques for massive weight loss contouring are being perfected, little attention has been placed on objectively assessing the outcomes of this operation," Dr. Shermak tells Cosmetic Surgery Times . "Our study set out to assess the range of variables that may play a role in developing surgical complications resulting from this operation and determine their effect on surgical outcomes." In the study, Dr. Shermak analyzed several patient factors including age, gender, medical co-morbidities (i.e., hypertension, cardiac disease, diabetes, hypothyroidism, asthma, obstructive sleep apnea, osteoarthritis, Ehlers-Danlos syndrome, gastroesophageal reflux disease, history of deep venous thrombosis and pulmonary embolism), depression, tobacco use and body mass index at the time of body contouring surgery.

RISK RELATIONSHIPS Study results showed that male patients had a significantly higher risk of developing wound dehiscence. This increased risk in wound healing was also seen in patients who had hypothyroidism and Ehlers-Danlos syndrome. Furthermore, Dr. Shermak noticed that asthmatic patients showed an increased risk for requiring blood transfusions. Data also revealed that having three or more body contouring procedures was associated with an increased risk of blood transfusion and an increased length of stay.

According to Dr. Shermak, the problems in wound healing seen in patients with Ehlers-Danlos syndrome is well documented in general and plastic surgery literature. These patients can present with joint hypermobility, skin extensibility, tissue fragility as well as abnormal scar formation and wound healing, due to defective collagen. "Although our series only included one patient with Ehlers-Danlos syndrome, making the significance of this finding low, this syndrome is certainly a factor that must be considered in determining the prognosis for potential failure in wound healing, and techniques must aim for conservatism," Dr. Shermak explains.

She notes that the relationship between male gender and hypothyroidism and the risks of wound dehiscence has also been previously reported in medical and general surgery literature, but not in plastic surgery literature. According to Dr. Shermak, past studies have shown that premenopausal women deposit more collagen than men in an experimental wound and that men demonstrate a decrease in the deposition of collagen as they age compared to aging women.

"This may be secondary to the effect of estrogen — although there may be other important factors, such as the difference in compliance between male and female patients. According to our results, we believe that male patients must be treated more conservatively than female patients," she says. Dr. Shermak also believes that there may be a relationship between patients with hypothyroidism and wound dehiscence. In her study, those patients diagnosed with hypothyroidism received thyroid replacement therapy. However, Dr. Shermak states that thyroid function testing had not been performed, as it was expected that these patients were corrected and that there may be a group within this population that did not receive adequate replacement therapy. "Testing the importance of thyroid function results would be a worthwhile study in the future," she says. "If an association can be made between T3 and T4 levels and wound healing problems, it would be important to test and ultimately correct these levels before performing any body contouring surgery."

USUAL SUSPECTS NOT GUILTY According to Dr. Shermak, factors such as age, hypertension, cardiac diseases, sleep apnea, diabetes, osteoarthritis, gastroesophageal reflux disease, history of deep venous thrombosis or pulmonary embolism, tobacco use, depression and body mass index at body contouring surgery have all been reported in the literature to detrimentally affect wound healing. Interestingly, however, her study showed that none of these factors are associated with increased risk of complication.