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Body contouring and the post-bariatric patient

Article-Body contouring and the post-bariatric patient

Key iconKey Points

  • MWL has become commonplace given the obesity epidemic and popularization of bariatric surgery
  • Post-bariatric contouring can be life changing for patients, with physical, social and psychological effects
  • For plastic surgeons treating MWL patients, technical procedures, patient management, and judgment issues can pose challenges

Dr. Borud
Only a decade ago, it was rare indeed for a plastic surgeon to see a massive weight loss (MWL) patient. How things have changed! With the popularization of bariatric surgery combined with the worldwide obesity epidemic, MWL has become commonplace. These trends have created special challenges for patients and plastic surgeons alike.

Unlike most other arenas of aesthetic surgery, post-bariatric body contouring can be a truly life-changing event for the patient, with major physical, social and psychological impact. Most overweight patients have struggled much of their lives with physical issues, medical comorbidities, self-esteem and body image problems and social discrimination. After the weight loss has been achieved, despite major improvements in health, patients are disappointed to see a substantial disconnect between their new healthy lifestyle and their sagging physical appearance. They are unable to fit into proper-sized clothing or look as good as they feel. Old body image concerns resurface worse than ever. In short, many patients find they are not enjoying life the way they should be because of all of the excess skin and other deformities present after MWL.

CONTOURING 'COSTS' Surveys have shown that nearly all MWL patients would like to have some form of body contouring surgery. The major roadblock, of course, is cost. With some exceptions, these procedures are aesthetic in nature. Except for the panniculectomy, third-party payors rarely "cover" body contouring procedures after MWL in the United States at this time. Optimally, patients would be educated much earlier in the weight loss process about what to expect financially as well as physically and emotionally after the weight loss process is complete and the patients are considering plastic surgery.

Surgeons must be at the forefront of providing patient education resources. This can be accomplished by speaking at support groups, adding specialized content to their web pages or other marketing materials, or giving talks to general surgery audiences and other groups of physicians.

Plastic surgeons who treat MWL patients are faced with a whole host of new challenges. The "old-fashioned" tried-and-true body contouring procedures yield sub-par results when directly applied to the MWL patient. Surgical innovators have had to adapt and update procedures and, in some cases, devise completely new procedures for dealing with these challenges. Although many plastic surgeons are interested in learning and developing experience in post-bariatric body contouring surgery, others — understandably — do not feel equipped in their practice setting to perform such large, labor-intensive operations with complication rates exceeding those of other aesthetic procedures. The interested plastic surgeons need to be committed to learning these new techniques by visiting other surgeons, attending conferences and reading the literature.

CHALLENGES & CAVEATS For plastic surgeons learning post-bariatric body contouring surgery, the technical aspect of the procedures is the tip of the iceberg — patient management and judgment issues abound. Surgery should not occur before the patient has achieved a new and stable weight for some months. In addition to the usual pre-operative evaluation for major surgery, the surgeon must focus on identifying and correcting malnutrition, which can be epidemic in these patients, yet unrecognized. Protein-malnourished patients will suffer massive wound-healing problems. Psychosocial issues are prevalent in this patient population, including depression, other mood disorders, personality disorders and substance abuse. Frequently, there is marital or relationship strife or an unstable family environment. Although most patients find some support among their friends, spouses or family for undergoing bariatric surgery, the same support is often lacking once the weight is lost and the patient is seeking plastic surgery.

Informed consent takes on a new and more complex dimension in these patients as well. In many cases, even the most skilled surgeons cannot produce aesthetic results analogous to aesthetic procedures in the non-MWL patient. BMI at the time of body contouring is, in our experience, the prime indicator of what results can be achieved. This is paramount in helping the patient formulate realistic expectations of outcome. The patient must also be advised about the physiological magnitude of these procedures including real possibilities of blood transfusion, DVT, pulmonary embolism, major fluid shifts, wound dehiscence, damage to lymphatics, unfavorable or asymmetric scarring, seromas and a high "revision" or "touch-up" rate from post-operative loosening of the skin or other causes. Patient safety is also more complicated in the MWL patient. Special attention must be devoted to issues such as obstructive sleep apnea, autologous blood donation and DVT prophylaxis.

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