By Andrew Wolfe, MD
Obesity and the constellation of diseases which result from obesity are among the most significant health problems in the United States today. In an effort to combat this epidemic, patients are increasingly turning to Bariatric Surgeons for massive weight loss surgery. Last year 200,000 Bariatric procedures were performed, representing a 10-fold increase over the previous decade. The benefits of the weight loss are profound and far-reaching. Physiologically, there are improvements in many weight-related conditions, such as diabetes, cardiovascular disease, and skeletal disorders. The psychological benefits include marked improvements in body image and social acceptance as well as decreases in depression and anxiety.
Although the weight loss is truly a life saving process, it is not without its negative side effects. Psychological challenges can include stressful changes in relationships with the patient’s spouse, friends, and the opposite sex. These changes can be so pronounced that patients may experience an identity crisis after weight loss, and psychological counseling and support groups are integral to the successful transition from obese to non-obese. Physically, the loss of fat results in disproportionately loose skin and underlying soft tissue, which can lead to both aesthetic and functional concerns.
For many massive weight loss (MWL) patients, Plastic Surgery is a vital step in their journey, and improves their physical and psychological well-being. More than 100,000 contouring procedures have been performed on MWL patients, and that number is growing exponentially. The goals of surgery are straightforward – improved function, hygiene and appearance, achieved through safe, predictable procedures. As straightforward as these goals may be, post-MWL Plastic Surgery is a rapidly-evolving specialty, and procedures are constantly evolving to offer patients better, safer results.
Prior to any elective surgery after MWL, preoperative considerations which must be taken into account include nutrition, weight stability, and smoking habits. Nutritional deficiencies are common after weight reduction surgery, although newer Bariatric procedures are less likely to affect patients adversely than were older techniques. Vitamin and protein levels are generally checked before surgery, and supplemented if necessary, in an effort to maximize the efficiency of wound healing. Weight stability prior to contouring procedures is beneficial, and most patients undergo Plastic Surgery 12 to 18 months after their Bariatric procedure. A minimum of 3 months at a stable weight is a typical benchmark, although 6 months of stability is preferred. Of note, some patients do find that contouring procedures lead to further weight reduction through increased activity levels postoperatively. All nicotine-containing products must be avoided around the time of surgery, as they significantly increase the risk of wound healing complications.
The types of procedures performed on MWL patients are different than those on non-weight-loss patients. Given the profound laxity that most patients exhibit, extensive excisional procedures are usually necessary, resulting in larger scars, longer recovery times, and greater risks. In addition to the increased amount of skin, the quality of the skin that remains after contouring procedures tends to be of poor quality – stretch marks, loss of elasticity, and atrophy of the skin are all to be expected. Because of this, secondary touch-ups and revisions are not unusual in this population, and should not be seen as failures of the original surgery. Fortunately, MWL patients tend to be very tolerant of scars, very motivated, and extremely satisfied with the dramatic improvements that these procedures can produce.
Procedure types are generally broken up into the lower body (abdomen, buttocks, and thighs), and the upper body (breast, back, and arms). MWL patients present with a wide variety of deformities, priorities, and expectations, and individualization of treatment is crucial to success. Many patients require more surgery than can safely be performed in one session, and a staged approach is usually necessary. The lower body is generally addressed first, as the abdomen is almost universally a priority for MWL patients. Second stage procedures address the upper body, while a third stage may be useful for thigh tightening and/or touch-ups. Facial procedures may also be performed.
Laxity of the skin and soft tissues of the abdomen can be pronounced after MWL, and virtually all patients require some type of abdominal tightening. An abdominoplasty, or “tummy tuck” corrects this laxity with a multi-layered approach that tightens skin and muscle while removing excess fat in the lower abdomen.
This diagrams illustrates the key steps of an abdominoplasty. The initial incisions are made around the umbilicus and in the lower abdomen, and the skin is lifted off of the underlying muscles up to the rib cage. The rectus muscles are then tightened. As shown, this tightening is generally done in a vertical fashion, although additional vectors of tightening may be added if significant laxity exists. The patient is flexed on the table, and excess skin is advanced down towards the pubis and excised. Finally, the umbilicus is brought up through the abdominoplasty flap and sculpted into position.
Photos of a 35-year-old woman who had lost 90 lbs, before and after an abdominoplasty.
Photos of a 44-year-old woman who lost 120 lbs after an open gastric bypass before and after an abdominoplasty. (She previously underwent an augmentation/mastopexy.)
Photos of 38-year-old woman who lost 180 lbs after a laparoscopic gastric bypass, before and after lower body lift with augmentation/mastopexy.
Surgical correction of the upper body includes the female breast, male chest, arms, and back. Female breast surgery is commonly performed after MWL with the goals of improving the breast shape, volume, and skin envelope. Given the loss of soft tissue integrity of the breast that comes with MWL, most patients will need some type of skin tightening, be it with a mastopexy, augmentation/mastopexy, or reduction. In some patients, this can be achieved with a vertical scar pattern, while others with more profound ptosis may need a Wise-pattern or “anchor” scar.
The preoperative breast volume may be ideal, in which case a mastopexy alone can be performed. In this operation, the breast gland is reshaped, and excess skin is removed. Although no volume is removed, the breast tends to appear smaller due to its more compact shape. Many patients present with breasts that remain too large even after weight loss, and a breast reduction is performed. Finally, patients may desire a breast that is larger and perkier than their current breast. A breast augmentation in conjunction with a mastopexy is then performed.
Photo of a 45-year-old patient before and after an augmentation/vertical mastopexy.
Arm laxity is an issue for many patients after MWL, and is corrected with an arm lift, or brachioplasty. A brachioplasty tightens loose arm skin, improves the contour of the axilla, and can be combined with liposuction of the arm if residual fullness exists. The degree of laxity often seen after MWL often requires a full brachioplasty as opposed to a more limited technique, and results in scars which extend to the inner elbow. These scars often heal very well but take years to fully mature, and are visible in a short-sleeved shirt.
MWL patients often experience premature aging of the facial soft issues in addition to those changes seen in other parts of the body. Loss of volume and elasticity in the face can be corrected with procedures that resuspend soft tissues and tighten the skin while maintaining or augmenting facial volume. Newer facelift techniques may afford patients shorter scars, a quicker recovery, and fewer complications. A popular technique is the “Short-scar Lateral SMAS-ectomy” facelift, developed by Dr. Daniel Baker. Also known as a “Mini-facelift”, this procedure offers significant improvement in facial shape with a surgery less aggressive than that commonly performed. Many patients choose to add other procedures such as eyelid surgery (“blepharoplasty”) or brow lift at the same time for a more complete facial rejuvenation.
The risks associated with these procedures vary widely. For many body contouring procedures, the scars are long and heal to varying degrees of fineness. Wound healing complications are more likely in smokers and those with poor nutrition. Secondary relaxation of tissues is certainly possible, even after an aggressive procedure, and revisions are common in this patient population. As previously stated, a revision should be seen as a fine-tuning or enhancement of a previous operation. Deep venous thrombosis, or DVT, is one of the most dreaded complications seen with this type of surgery. During surgery, or in the postoperative period, these clots can form in the deep veins of the legs and have the potential to migrate to the lungs as a pulmonary embolism, a potentially fatal complication. A key intraoperative step to prevent DVT’s is the use of pneumatic compression devices that are applied to the legs. Early ambulation after surgery is also important. The risk of DVT is increased in the obese, older patients, smokers, and patients taking birth control pills. If multiple risk factors are present, short-term treatment with an injectable anticoagulant such as Fragmin or Lovenox may be used.
The postoperative recovery after surgery can range from less than a week for some breast procedures to three weeks for a lower body lift. Most breast procedures require a week off from work, and result in postoperative discomfort that requires prescription pain medication for three or four days. Lighter exercise may be resumed in two weeks, while more vigorous activities such as yoga or Pilates should be avoided for three or four weeks. In contrast, abdominoplasties and body lifts often require two tow three weeks off of work, with lighter exercise resuming at three weeks. Strenuous activities should be avoided for six weeks to allow adequate healing of the lifted tissues. Facial procedures tend to result in relatively mild discomfort, but patient appearance may dictate a two-week avoidance of social activities.
In summary, the field of Plastic Surgery after MWL is rapidly advancing. For these patients, safety is first and foremost, and a systematic approach to presurgical, intraoperative, and postoperative care can reduce complications. Communication, patient education, and informed consent are crucial, and patients must have realistic expectations. Finally, individualization and timing of procedures should be based on patient anatomy and patient priorities. Despite the challenges MWL patients present, the rewards for both surgeon and patient can be great.
About the Author
Born and raised in New York, Dr. Andrew Wolfe operates his practice, “The Center for Cosmetic Surgery,” in Denver, Colorado. Dr. Wolfe is passionate about his work, and thoroughly enjoys both the personal and technical aspects of the specialty. He believes that the physician-patient relationship is truly a partnership. “I have to understand a patient’s history, desires, and physical status before I can recommend a course of action. At the same time,” Dr. Wolfe says, “the patient has to learn about the various options available for any given procedure before they can make an informed decision.” Patient education is a high priority at the Center for Cosmetic Surgery, and Dr. Wolfe spends a great deal of time with his patients, both before and after surgery, making sure that they understand their surgical options. At the Center for Cosmetic Surgery, Dr. Wolfe has created a blend of state-of-the-art techniques and more traditional approaches. “I’m not shy about adopting new techniques or procedures”, he says, “but I need to be sure that they are safe and effective first.” Above all, Dr. Wolfe feels privileged to be able to be able to perform the work he does. “Virtually everything I do is elective, and I consider it an honor to be chosen by a patient to perform their surgery.” Learn more about Dr. Wolfe.