Plastic Surgery Following Weight Loss

1. Analyze deformity and patient

2. Be efficient in design and execution

3. Excise excess as much as possible transversely

4. Position incisions favorably, and respect scars

5. Focus on the ultimate contour and tissue tension

6. Preserve healthy dermis and subcutaneous fascia

7. Remove fat from flaps gently and effectively

8. Make closure tight and secure

9. Minimize swelling, infection, phlebitis, and seroma

10. Analyze your experience

This chapter presents the patient profile, preoperative preparation, and operative planning. There is a summary of the operative technique, as well as selected case presentations. Advances since the first edition of this text will be highlighted. The principles of treatment are detailed, followed by an evaluation of the surgical outcomes. Over the past 12 years, this author has performed over 1,600 procedures on more than 500 patients after massive weight loss, pregnancy, or aging. These include singly or in combination abdominoplasty, lower body lift, upper body lift, medial thighplasty, brachioplasty, mastopexy, breast reduction, facelift, gynecomastia correction liposuction, and lipoaugmentation. The body mass index (BMI) ranged from 24 to 42. Due to the potential of a high rate of complications, we have treated few patients with morbid obesity [9].

Patient Profile

Obesity is a stigmatizing disorder, especially among women, which may explain why women predominate in seeking weight loss treatment [2]. The increased demand is due to word-of-mouth comments on the improved results and lower morbidity, supported by reports in scientific journals, the Internet, and the media [10]. Over 80 % of the patients in this series seeking body contouring after weight loss are women.

Most patients report to me that their laparoscopic bypass operation was brief, followed by easily controlled pain. Through four to six small incisions, their peritoneal cavity has been inflated to expose intestines for rerouting and/or partition over what has routinely become a 2-h session. They are discharged within days to return to work within a week. Those who are converted to open procedures due to technical considerations tend to have a slightly more prolonged postoperative course. Delayed wound healing and incisional hernia are common in the open group. Extensive scars and abdominal hernias are important considerations in abdominoplasty planning.

With small gastric pouches and a moderately long Roux-en-Y jejunal bypass (the length varies directly with the degree of obesity [11]), the patients shed pounds rapidly due to limited intake, reduced absorption, and early satiety. Many experience mild gastrointestinal dumping after minimal sugar or fat intake. Most become uninterested in food, which may be a hormonally mediated change. All are encouraged to maintain a small caloric multiple-meal diet and an active exercise program, in anticipation of increased gastrointestinal capacity over time. In general, patients lose weight because of reduced food intake and increased physical activity and not intestinal malabsorption. Many become champions of bariatric surgery and encourage others at a variety of organized support group meetings. Most have been introduced to the results of plastic surgery at these group meetings and individually through the bariatric nurse coordinators, who have personal experience. A referral program called Life after Bypass has been instituted at the University of Pittsburgh. Patients receive automatic appointments and an informative brochure about body contouring surgery, shortly after their bypass. Patients find their way to the Hurwitz Center for Plastic Surgery through Internet searches, word-of-mouth referrals, and national television programs featuring the total body lift (the author’s signature procedure).

After a steady weight loss to about 70 % of their excess weight over 18 months, most regain about 20 % over the next few years [12]. Therefore, if a patient’s weight loss reaches a plateau, waiting beyond 18 months before initiating body contouring surgery is counterproductive. Commonly, over the next year patients gain much of the weight removed during body contouring surgery. On the other hand, in some patients unanticipated further weight loss occurs, from 20 to 60 lb, because of partial gastrointestinal mechanical obstruction. This causes malnutrition reflected in low serum prealbumin fraction, anemia, and measurably low trace elements [13]. The nutritional deficiency may prolong what would otherwise be minor wound healing problems [14]. Additional weight loss results in new skin laxity, which will detract from what could have been an optimal outcome.

The patients who struggle with their layers of hanging skin and fat and have the courage to consider surgery present to plastic surgeons. When obese, their massive size presented an unappealing but recognizable shape. Hanging skin distorts the body shape and patient age and appearance, and it flaps around during vigorous activity. Skin beneath folds becomes moist, malodorous, and inflamed. Clothes fit poorly. Embarrassment of their hanging pannus, mons pubis, and inner thighs thwarts sexual intimacy. While many comprehend that plastic surgery is an anticipated part of their rehabilitation, they still may resent and even regret the bypass operation. The plastic surgeon’s empathy is important, especially when asking the patient to accept the new risks and self-pay costs of body contouring surgery. If the patient has limited financial means, we offer national cosmetic surgery finance plans at reasonable rates for those with good credit.

With the ease of convalescence, effective weight loss, improved exercise habits, and encouragement from others who have gone before them, patients are accepting of the arduous body contouring procedures yet ahead. The opportune time to perform body contouring is when the patient has completed the catabolism and has reduced comorbidities. These include sleep apnea, hypertension, gastroesophageal reflux disease (GERD), cardiomyopathy, diabetes, leg edema, osteoarthritis, and mental depression. Because of their diseases and prolonged postoperative negative nitrogen balance (starvation), we avoid panniculectomy coincidental to the intestinal bypass. Moreover, the panniculectomy scar may preclude optimal subsequent surgical planning for definitive contour correction.

We find most patients understand the goals and limitations and the need for multiple stages and possible revisions. We impress upon them that optimal contour improvement entails a very tight closure with risk of suture line dehiscence. If that complication is unacceptable, then less pull will be made. While the scars are generally thin, they may be thickened and uneven. After revealing the common and serious risks of their operations, we offer a detailed consent form for each procedure. We have established a Web site (www.hurwitzcenter.com) that patients may visit before the first office appointment. They learn about the surgery, see results of operations on a variety of patients, and are cautioned about the risks. There is a detailed intake form, which is instructive to the patient and gathers important information for the surgeon. The Hurwitz Center for Plastic Surgery sends each patient who seeks a consultation a complimentary copy of a consumer directed book, Total Body Lift: Reshaping the Breasts, Chest, Arms, Thighs, Hips, Back, Waist, Abdomen, and Knees After Weight Loss, Aging, and Pregnancies, published by MDPublish, New York, New York, 2005. We attempt to exclude candidates suffering from chronic medical and psychiatric illnesses and those with unrealistic expectations.

Digital imaging is used during the second visit several weeks before the scheduled surgery. The patient’s preoperative photographs are displayed. Electronic pens allow for drawing anticipated incision lines, indicating the direction of tissue tensions and final scar placement on multiple views of their images. Their new silhouette can be drawn, but no promises are made. Technique and outcomes vary according to the patient’s basic body habitus. Oversized people, endomorphs, cannot be transformed into ectomorphs. During office follow-up, impatient and disappointed patients, as well as pleased patients, are graphically reminded of the extent of their original deformity by having a monitor with all possible images available within view of the examination room.

The surgeon considers the body shape (endomorph, mesomorph, or ectomorph), extent of deformity, size, sex, patient priorities, lifestyle, and tolerance for risk. Before embarking on such lengthy procedures, the surgeon and the support team and hospital should have experience working together on less extensive procedures. Three days of hospital care are essential. The larger the patient and the longer the procedure, the more likely are complications.

The Deformity

The massive weight loss patient has a deflated shape based on familial and gender-specific fat deposition and skin to fascia adherence. The most susceptible regions are the anterior neck, upper arms, breasts, lower back, flanks, abdomen, mons pubis, and thighs. In men there is a tendency to accumulate fat around the flanks, intra-abdominally, and the breasts. In women the fullness lies in the subcutaneous fat of the abdomen, hips, and thighs. Patterns of deformity are emerging that seem to be affected by the magnitude of initial BMI and change in BMI.

Redundant skin hangs over regions of fibrous adherence to deep fascia (Fig. 1 ). The skin of the trunk is densely adherent along the inframammary fold, down the upper midline to the linea alba, and in the groin. Adherence is variably dense across the rectus abdominis transverse tendinous inscriptions (more so in the male) and along one or two transverse levels across the anterolateral ribs, flanks, and back. Skin flaps undermined beyond adherences will readhere after the operation and have less tension on the skin, which explains why the epigastrium usually maintains an unwanted roll after an abdominoplasty.

Fig. 1.

Massive weight loss deformity varies according to the original fat distribution and pattern of skin adherence. (a) This 33-year-old, 203-lb woman lost 300 lb 2 years after Roux-en-Y gastrointestinal bypass. She has a large hanging pannus and considerable skin laxity in the mid-torso, hips, and medial thighs. The redundant skin and fat torso rolls cascade from midline to lateral. There is an anterior midline adherence along the linea alba and umbilicus, which is somewhat accentuated in the epigastrium by her vertical surgical scar. There are paramedian vertical folds reflective of the semilunar lines along the lateral rectus margins extending from the costal margins to the end of the hanging pannus. Beginning with the inframammary folds, there is an asymmetrical stairstep array of transverse skin adherences. Immediately superior to the costal margin, the skin is broadly adherent, more on the left than on the right side. Inferiorly, two transverse lines reflecting the tendinous inscriptions cross from lateral rectus border to the midline in the epigastrium and at the umbilicus. (b) On lifting the pannus, one sees the broad adherence along the iliac crests, across the suprapubic region, and diverting along each labial thigh junction. There is a progressive lateral flowing of rippled skin from upper medial thigh to the suprapatellar region. ( c ) Back folds begin inferior to the scapula. The left back has two oblique lines of back fascia adherence, while the right has a series of three. The last rolls overlap the pelvic rim. The firmly adherent central buttock fullness is framed laterally and inferiorly by numerous thin folds of lax skin. The posterior and lower lateral thigh skin below the lateral trochanter is broadly adherent to the fascia lata. The markings for a circumferential abdominoplasty, lower body lift, and medial thighplasty are drawn. Surgical lines for the first stage have been drawn while the patient reclines, pulls her pannus out of the way, and stands. The vertical lines ensure proper alignment for closure. The markings begin with the patient reclined and pulling up on her pannus. A 14-cm transverse line is centered about 8 cm above the labial commissure. With firm oblique upward pull on the pannus to the opposite costal margin, the incision line is continued across each groin and over the anterior superior iliac crests. The inferior incision continues across the hip with the patient in lateral decubitus and abducting the thigh. With all excisable skin drawn cephalad, the transverse line extends posteriorly to end immediately superior to the intergluteal fold. When the patient is standing, as seen here, the line dips inferiorly to the extent there is lateral thigh skin laxity. The anterior superior incision is along the umbilicus and is planned by pulling down the superior flap to the bikini line, because unraveling upper redundancy will be limited by costal margin skin adherences. The medial thighplasty has an inner line along the labial thigh groove extending to border the lateral mons pubis. The outer line is an estimate of skin removal, aided by the patient raising her leg while in the supine position. The posterior extension of the medial thighplasty overlies the ischial tuberosities and ends along the inferior gluteal folds.

Both anteriorly and posteriorly, there is medial to lateral staggered sweep of redundant tissue. Thigh skin is adherent below the anterior superior iliac spine, along the midlateral and midmedial regions and to a lesser extent along the entire posterior thigh. By the time the weight loss plateaus, the amount of fat within this redundant skin varies considerably. With massive weight loss, there are extensive layered folds or wrinkling. The skin is like an oversized suit and in no dimension, vertical or horizontal, is there normal skin tension. Unlike posttraumatic or congenital deformity surgery, there is no displaced normal tissue to relocate. All the skin is disordered and is treated accordingly.

Etiology of Skin Laxity

The etiology of skin laxity after rapid weight loss is inadequately understood. The subdermal to aponeurosis fibroelastic spans, overflowing with adipocytes in the obese, have fractured elastin fibers on microscopic study. The damaged elastin and collagen allow for no skin retraction after weight loss. With rapid weight loss, there is no way to prevent sagging of the abdominal skin, skin of the breasts and buttocks, and the inner portions of the arms and thighs. It is important to repair the abdomen with the best quality of skin, usually from the upper portions. Unfortunately, in massive and rapid weight loss patients, there is usually no quality skin. The problem is compounded in individuals over 55, who lose considerable skin elasticity without weight loss. Until we are able to reverse this complex disorder of subcutaneous disease, we are forced to excise the widest possible areas of skin and then close the skin flaps as tightly as possible.

Three factors contribute to postoperative skin laxity. First is the diseased skin collagen and elastin. Second, the farther the skin is from the line of closure, the less effective is the pull. I refer to this as the law of skin laxity. Otherwise stated, skin laxity is corrected closest to the line of closure and is progressively increased farther away. Third, the adherence of the skin to underlying fascia prevents tightening beyond the adherence. Surgical disruption of these customary and unique adherences mobilizes the flaps, but since perforating blood supply usually occurs there, flap vitality may be compromised.

As yet there are no proven means to improve skin and subcutaneous tissue elasticity. I am pleased with the applicability of Endermologie (LPG, Montreal, Canada), a computer-modulated differential vigorous massage and suction machine, to treat these patients. LPG claims that significant skin laxity can be reduced with about 20 twice-weekly treatment sessions. We have initiated treatments to improve our surgical results and substantiate this claim. We are convinced that if expertly performed, Endermologie hastens resolution of postoperative performed, Lipomassage^® reduces swelling and induration. It softens most hypertrophic scars and reduces scar-related neuralgia. It is Food and Drug Administration (FDA) approved to temporarily improve cellulite. We find that minor contour deformities are smoothed by these treatments. There is experimental evidence in pigs that subcutaneous organized collagen can be produced by these treatments over a short period of time [15]. Clinical studies have failed to show a reliable improvement for contour deformity but show promising results for cellulite and as a helpful adjunct to ultrasonic and traditional liposuction [16–19]. The recent introduction of advanced electronic technology into the CELLU 8 promises to deliver on improved body contour sooner.

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