Massive model

Soaring obesity rates in the U.S. are directly affecting the plastic surgery industry as an increasing number of patients who have experienced massive weight loss following bariatric surgery find themselves in desperate need for body lifts. The number of weight loss surgeries in the U.S. increased from 28,800 in 1999 to 171,000 in 2005, according to the American Society of Bariatric Surgeons, and, as a result, post-bariatric surgery has become one of the fastest evolving specialties in plastic surgery. Lower body lifts, for instance, soared from just 207 in 2000 to 10,323 in 2006 — a whopping 4,887 percent increase, and upper arm lifts jumped from 338 to 14,886 in the same period — a 4,204 percent increase, according to the American Society of Plastic Surgeons (ASPS).

The total number of body contouring procedures performed specifically for massive weight loss patients exceeded 68,000 in 2005, the ASPS reports. "This represents a whole new population coming to the cosmetic surgeon," Gary M. Brownstein, M.D., a board-certified plastic and reconstructive surgeon based in Cherry Hill, N.J., tells Cosmetic Surgery Times . "A lot of plastic surgeons are adding [body contouring] to their practices."

While body lifts are not new to plastic surgery, surgeons who venture into the field of post-bariatric surgery find themselves challenged with the task of performing unique — and usually multiple — surgeries, Dr. Brownstein adds.

Such work with post-bariatric patients requires collaboration with a multitude of other health professionals to address patients' various physical and psychological needs.

PARTNERING FOR THE PATIENT At the University of Pittsburgh Medical Center (UPMC), plastic surgeons have refined such collaborations to an art in the form of a multidisciplinary treatment center for post-bariatric patient care called the Life After Weight Loss clinical program.

The center promotes team-building efforts and core partnerships with nutritionists, lifestyle counselors and psychological professionals — all of whom are present in the clinic to evaluate patients alongside the plastic surgeon. "There are so many issues other than the plastic surgery that affect the post-bariatric patient," says Madelyn Fernstrom, Ph.D., director of the Weight Management Center at the UPMC.

"Their nutritional status is extremely important, for instance, because patients can't absorb nutrients, so they have to take vitamins and minerals as supplements and this translates directly to plastic surgery in terms of wound healing," she explains. Consequently, the UPMC program provides a separate nutrition evaluation and consult to make sure that the patient's protein intake is more than sufficient because failure to take in enough protein can translate to difficulty in wound healing and the risk for incision infection.

In a recent paper on their model program, the UPMC researchers describe it as being built around the center of excellence concept that applies to many disease specialties. The concept brings together specialists from a multitude of disciplines to treat patients in high volume. The UPMC team believes that the knowledge gained from the experience can only help to further improve quality of care. Clinical data obtained from the facility has, in fact, allowed the UPMC to set up a prospective clinical registry to track data from all stages of post-bariatric surgery and made possible the surveillance of long-term outcomes and assessment of clinical methods.

The UPMC program also takes advantage of the large mass of adipose tissue removed during body contouring procedures to study adipose biology, and efforts include a line of research for investigating the clinical potential of adult mesenchymal stem cells that reside within fat tissue.

Through the program's team approach, defined screening procedures and patient care algorithms have been set up to provide consistency in care.

The algorithms include a pre-operative evaluation looking at physiologic, psychological and anatomic factors; patient safety measures in the operating room, such as calf sequential compression devices for all patients prior to the induction of general anesthesia; and standardized post-operative physician order sets used to ensure consistency of care and help prevent a multitude of post-operative complications, which are not uncommon.