Screening for Medical Problems

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.

Physical Examination

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.

Weight Stability

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.

Favorable BMI

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.

Nutritional Status

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 Stability

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.

Goals and Expectations

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.

Patient Safety

First and foremost is patient safety. While there is no evidence to support a maximum operative time, some suggest that a 7-hour upper limit of total anesthesia time is reasonable for selected patients.^13,14 In a clinical review comparing single-stage multiple procedure body contouring cases versus two-stage procedures, it was found that single-stage surgery averaged 8.4 hours while two-stage procedures averaged 7.4 hours for the first stage and 4.6 hours for the second stage, totaling 11 hours. Complications and wound healing problems were comparable between the two groups and the complication rates for the individual procedures remained constant when procedures were combined.¹⁵ Importantly, the majority of complications noted are local wound complications. Therefore, while the overall complication rate is higher for multiple procedure cases in well selected patients, the rate is equal to the sum of the complication rates for the individual procedures.

Surgeon Experience and Setting

While it may be feasible to do two or three procedures in a single stage, the surgeon should be guided by his or her level of experience, experience of the OR team, and treatment setting. Pitanguy set forth criteria when combining multiple procedures into one operation. These include: a skilled surgeon that is experienced at performing multiple procedures, anesthesiologists adept at handling these cases, and an operative team able to assist in the case.¹⁶ As mentioned earlier, combining procedures in well selected patients will increase the overall rate of local wound complications (additive based on “per procedure” complication rates), but the incidence of major complications is unchanged.¹⁷ Caution should be exercised in the surgery center setting should combined procedures be entertained, and the length of operative time and/or number of procedures performed in a single anesthetic may be regulated by legal code.

Patient Preference

It is important to focus on the individual patient’s goals. Our approach is to ask patients to list the regions of their bodies that they would like to correct in order of priority. We then discuss surgical options that would affect changes in these regions, including the location of the scars and the extent of recovery. We emphasize the concept of trading excess skin for scar and assess the patient’s willingness to accept these scars. We also emphasize that having adequate time available to recover from the procedure is something that should be addressed before surgery; this will allow patients to make arrangements with their employer or, if necessary, delay surgery until a more suitable time. A patient must have a strong social support network with particular attention to having someone who can care for the patient during their recovery time. Lastly, patients are informed that relapse of skin laxity is unpredictable and can be severe enough to require operative revision. When a patient is a good candidate for multiple procedures, what is the ideal combination of procedures to perform at one setting? There certainly is no clear answer, and it is important to remember that performing multiple stages is never a wrong answer. As with all our plastic surgery patients, be guided by what is safe for the patient and what will provide the optimal outcome while minimizing the postoperative complications.

Considerations for Combining Procedures

There are a number of body contouring procedures that can be combined in one operative setting. Below we will review some of the more common combinations and caveats to be aware of when assessing each patient. Detailed technical aspects of the procedures mentioned below appear in other chapters addressing the respective topics. Clinical examples of staged body contouring cases are shown in Figs 55.1–55.4.

FIG. 55.1 A 58-year-old woman following 73 kg (160 lb) weight loss from roux-en-Y gastric bypass who desired dermal suspension mastopexy and abdominoplasty, a combination of procedures that is generally favorable, and brachioplasty.

Preoperative photographs (A–D) and postoperative photographs at 1 year (E–H) are shown. No significant change in buttock or trunk contour is effected form this combination, as expected. The patient returned desiring additional body contouring of the buttock and trunk. A second stage circumferential body lift was performed and the scars merged with the abdominoplasty scars, along with a limited lateral chest transverse resection to correct upper trunk contour. If a full transverse upper body lift was planned, it would have been staged relative to the lower body lift to avoid opposing vectors of tension. Postoperative photos are shown 2 years after the first stage (I–L).

FIG. 55.2 Brachioplasty photographs for the patient in Fig. 55.1 shown preoperatively (A), 1 year (B), and two years (C) postoperatively demonstrating maturation of the bicipital groove scar.

FIG. 55.3 A 43-year-old woman after 55 kg (120 lb) weight loss from gastric bypass (A, B). Circumferential debulking liposuction was employed in first stage with 4 l of aspirate removed from each leg concurrent with circumferential lower body lift and fleur-de-lis abdominoplasty (C, D). This was followed 6 months later with a staged vertical medial thighplasty, with 1 month photographs shown (E, F).

FIG. 55.4 A 46-year-old woman with 100 kg (220 lb) weight loss following roux-en-Y gastric bypass with BMI of 25 kg/m² and good medical profile.

Multiple procedures were desired to correct deformities throughout the body (A–C). Two stages were planned. In the first stage, a circumferential lower body lift was performed, along with a fleur-de-lis abdominoplasty and brachioplasty. Postoperative photos from the first stage are shown at 4 months, just prior to the second stage (D–F). At the second stage, a dermal suspension mastopexy, circumferential upper body lift, and vertical medial thigh lift were performed. Postoperative photos are shown 1 year after first stage (G–I).