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Overcoming surgery safety challenges in patients after massive weight loss

National Report — While massive weight-loss patients and their plastic surgeons stand to gain dramatic benefits from the circumferential belt lipectomy procedure, the stakes of the surgery are high, with significant potential for seromas, wound separations, infections and psychological breakdowns that can alter patient care.

It is critical that surgeons not only know what can happen as a result of this type of surgery but also take steps to avoid potential pitfalls, according to Al Aly, M.D., a plastic surgeon in private practice in Iowa City, Iowa. Dr. Aly has played integral roles in educational efforts for surgeons and patients provided through the American Society for Aesthetic Plastic Surgery (ASAPS). He was among the contributors to an ASAPS patient CD on the topic of plastic surgery for massive weight-loss patients. He puts together symposia on the topic at national meetings and is featured in a panel discussion on body contouring after massive weight-loss surgery in the Sept.-Oct. 2004 issue of Aesthetic Surgery Journal (Vol. 24. No. 5).

No quick fix Many of today's massive weight-loss patients are post-bariatric surgery. Those procedures can have significant impact on patients' physiological conditions, which include hemoglobin and calcium levels, as well as overall nutrition.

"Essentially, bariatric surgeries can be divided into two types. There are restrictive procedures, which cause a narrowing in the food passage and prevent patients from taking in large amounts of food at any one time. Those patients may or may not have difficulties with absorption of certain nutrients," Dr. Aly says. "The second category of bariatric surgery procedures bypasses segments of bowel, where the food bolus is rerouted distally in the bowel, leading to a decrease of absorption of nutrients. This type of surgery has the potential of leading to significant malabsorption."

Often, it is wise for the plastic surgeon to seek the advice of the bariatric surgeon who originally performed the weight-loss surgery on these patients, especially when determining a particular patient's nutritional status, whether the patient is on appropriate nutritional supplements, and whether the patient has stabilized his or her weight loss, according to Dr. Aly.

These patients present with a variety of aesthetic complaints; most commonly, a hanging panniculus. Although the panniculus is the most obvious aspect of their presentation, their truncal contour deformities are rarely limited to the front of the body. Rather, these deformities most often go around the trunk circumferentially, to affect the lateral and posterior contours, according to Dr. Aly.

Because of the effects of massive weight loss on the bodies of these patients, Dr. Aly says, ideally the plastic surgeon should see patients prior to their bariatric procedures, although this hardly ever happens. Often patients are not aware that their body contours will not revert to normal after the weight loss. By meeting early, plastic surgeons can better prepare patients for the resultant deformities that are likely to occur.

"Unfortunately, a lot of these patients are under the impression that their bodies will go back to normal when they lose the weight," Dr. Aly says. "Some bariatric surgeons discuss what patients should expect, but often it is best for us, as plastic surgeons, to take that on."

Another benefit of early consultations with a plastic surgeon is to help future massive weight-loss patients visualize what they can accomplish in the long run.

"It gives them a concrete goal to go after, and that is always good when they are going through such a long and difficult process," Dr. Aly says. "The early visits also give us the opportunity to prepare them for the fact that most of the plastic surgery procedures that they need most often are not covered by insurance."

One way to get patients to see you early in their weight loss process is to attempt to interact with bariatric patients; let them know that you are available; educate them about what you can accomplish; and, hopefully, develop a good working relationship with them, Dr. Aly says.

Another way is to reach the patients directly.


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