Chapter 55 Staging and combining procedures
The key to body contouring surgery after massive weight loss is to understand which combinations of procedures can be safely combined in a given case. Patient selection is of utmost importance. When an individual would like to target multiple areas, a staged operative plan can be advantageous. Staging allows achievement of optimal esthetic results while minimizing postoperative complications. The cornerstone of safe and effective combined and staged procedures is a thorough patient workup.
Individuals seeking body contouring surgery after massive weight loss have changed their lives dramatically. Despite their significant weight loss, they retain the stigmata of their obese state in the form of loose hanging skin. It is important for the plastic surgeon to recognize and appreciate that patients may still view themselves as obese. Patients look for a specialist who understands the emotional as well as physical needs of the massive weight loss patient, and their comfort with the surgeon will be influenced by perceived sensitivity to self esteem issues. We often start the interview by congratulating the patient for the progress they have made in the process of weight loss and for taking steps to reclaim their lives.
Evaluation begins with a detailed history. In particular, it is important to obtain a thorough weight loss history. The method of weight loss and type of bariatric procedure provide important data on the potential for nutritional deficiencies, amount of expected weight loss, and time to plateau. Other relevant information includes date of bariatric surgery, maximum BMI, current BMI and change in weight over the past 3 months. This information can aid in determining if the patient has weight stabilized and is a good candidate to proceed with body contouring surgery.
A relevant nutritional history should be obtained. The majority of weight loss patients will have adequate intake for the unstressed state. Major surgery, however, can increase the body’s nutritional requirements by 25% and many weight loss patients may have physical impedance to increasing oral intake.1 Please see Chapter 54 for further details.
One area that may be overlooked in the preoperative evaluation, which is essential to the postoperative recovery, is the patient’s social support network. It is necessary to define who will be available to help take care of the patient at home in the initial postoperative period, especially if multiple combined procedures are contemplated.
The key focus is patient safety, and a history of significant medical problems, including hypertension, ischemic cardiac disease, sleep apnea, and diabetes, must be fully delineated and addressed before body contouring surgery. While most medical comorbidities of obesity are significantly improved, if not resolved, following weight loss, the plastic surgeon must search for residual disease. Inquiring about any recent changes in medication doses can help determine if the disease state is in equilibrium or is still in a state of flux. This is a good indicator as to whether the body is still working to achieve a level of homeostasis after weight loss.
Exercise tolerance is a useful indicator of surgical risk. Patients who routinely engage in 45 minutes of vigorous exercise without shortness of breath or other symptoms will likely tolerate the stress of surgery. However, beware of the inactive patient. These patients may have cardiac disease that will be unmasked by a major surgical procedure. We advise consultation with medical consultants, as warranted, for preoperative evaluation and recommendations for managing chronic disease states. Patients who smoke are advised to stop at least 4 weeks prior to surgery.
All aspects of a thorough physical exam should be included in the initial patient evaluation in order to fully appreciate the deformities and screen for residual medical problems. The massive weight loss patient will present with a wide range of physical anomalies. Body type (truncal versus peripheral obesity), remaining adiposity, rolls/folds and rashes should be noted. Body fat distribution will vary greatly in this patient population and will influence surgical options. Attention should be given to the patient’s skin tone and elasticity, as well as regional variations in skin elasticity. On the abdominal exam, make note of previous scars, the presence of any hernias, degree of diastasis, and overall laxity of the abdominal wall. To facilitate analysis of deformities in each anatomic region of the body, a four point rating scale can be applied. The Pittsburgh Weight Loss Deformity Scale is a tool to delineate the severity of deformities.2 An increased score correlates with a more severe deformity requiring a more extensive surgical procedure for correction.
Patient selection must be focused on maximizing safety and minimizing complications. With that goal in mind, the following criteria are desirable: (1) the patient should be weight stable for at least 3 months; (2) BMI should be favorable; (3) good nutritional status confirmed; (4) medical and psychosocial stability determined; and (5) reasonable goals and expectations communicated.
Prior to body contouring surgery a patient should be weight stable for at least 3 months (usually occurs between 12 and 18 months after GBP). We define stability as no more than 2.5 kg (5 lb) change in weight per month over the previous 3 months. Nutritional homeostasis and a positive nitrogen balance are necessary to facilitate the healing process.3 Additionally, a more predictable outcome can be achieved when the patient is not actively losing weight.
A high BMI is associated with increased wound healing complications.4,5 As the patient’s BMI decreases, we are able to offer more safe surgical options and expect better esthetic outcomes.6 The best candidates have a BMI of 28 kg/m2 or less. We are more cautious in our level of intervention with patients who have a BMI between 29 and 32 kg/m2. Patients with a BMI between 32 and 35 kg/m2 should be selected with great care. If a patient in a high BMI range desires significant contouring, we recommend delaying the operation until further weight loss can be achieved. We work on a weight loss plan with the patient and nutritionist and schedule a 2–3 month follow up appointment. This way the patient will remain under your care and not feel abandoned; moreover, you are able to serve as a motivating force. Some patients in a high BMI range may benefit from a first stage breast reduction or simple panniculectomy if such a procedure would improve their ability to exercise and progress with further weight loss. For patients with a BMI greater than 35 kg/m2, our practice in most cases is to defer operations because of increased risk of complications and less potential for satisfying esthetic results.5,7 Patients in this BMI range may be offered a functional panniculectomy, with strict indications of severe panniculitis or a profoundly disabling pannus.
The importance of the nutritional status of the post-bariatric patient cannot be over-stressed.8–11 If the patient has symptoms of persistent nausea and vomiting, have them see their bariatric surgeon to rule out a stricture or a treatable cause. Because gastric bypass patients have altered gastrointestinal physiology and subsequent dietary issues, nutritional deficiencies are not uncommon.12 In our center, we require patients take at least 75–100 g of protein per day before elective body contouring surgery. A patient who is incapable of consuming 75 g of protein per day is often not a good surgical candidate and dietary modification is essential. Please see Chapter 54 on nutritional assessment.
Medical and psychosocial issues must also be stable prior to any operation. Patients with significant medical comorbidities are routinely sent to an appropriate medical specialist for further evaluation and clearance. An adequate social support network should be in place. Active smokers are encouraged to stop at least one month prior to surgery. Our preference is to defer surgery for active smokers. If necessary to operate on an active tobacco user, then the extent of the procedure performed, especially the amount of tissue undermining, is limited. Similar caution is exercised with diabetic patients and those treated with steroids. Patients under the care of psychiatrists or psychologists should be cleared by their mental health provider prior to surgery.
The final component is to ensure that the patient has a reasonable set of goals and expectations. Patients must be willing to accept extensive scars in exchange for loose skin, understand both the power and limitations of the intended procedures, and appreciate which areas of the body will not be affected by the planned surgery. This last point is important because improving one area of the body may highlight deformities in adjacent areas.