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San Antonio Medicine
February 2008

SKIN DEEP
Post–Bariatric Body Contouring Surgery Can Benefit Formerly Overweight Patients

By Virginia A. Pittman–Waller, MD, MPH

Obesity is widely recognized today as a serious health problem in the United States. It is defined by the Centers for Disease Control and Prevention (CDC) as a body mass index of 30 or greater. The BMI is calculated by dividing a person's weight in kilograms by their height in meters squared. Although not a perfect system — many athletes qualify as "overweight" even though they are mostly muscle with 6 percent body fat — it provides a reasonable indicator of body fatness for most of the population.

According to the most recent CDC statistics released in November 2007, more than one- third of U.S. adults were obese in 2006, including 33.3 percent of men and 35.3 percent of women. Almost two-thirds of the population is either overweight or obese. The most obese age group is men and women ages 40 to 59, with a rate of 40 percent and 41 percent obesity, respectively. Within that age group, approximately 53 percent of black women, 51 percent of Hispanic women, and 39 percent of non–Hispanic white women were obese. Obesity rates among men were slightly lower.

Surprisingly, after decades of steady increase, the rate of overall obesity in the United States has remained statistically stable since 2004. Obesity rates for women have remained fairly level since 1999, with men catching up in recent years.

The prevalence of obesity today has led to a rapid increase in bariatric surgery. According to a study published in the Journal of the American Medical Association in 2004, the average weight loss for bariatric patients was 61.2 percent, with substantial health improvements for patients with type 2 diabetes (eliminated or improved in 86 percent of patients), hypertension (eliminated or improved in 78.5 percent), obstructive sleep apnea (eliminated or improved in 85.7 percent), and high cholesterol (reduced in 70 percent). Appropriate candidates for bariatric surgery have a BMI of 40 or more or a BMI of 35 with one of the conditions mentioned above.

In 2007, more than 200,000 patients were predicted to have bariatric surgery, according to the American Society for Metabolic and Bariatric Surgery. As a result of the number of bariatric surgeries today, there has been a resulting jump in the number of body contouring procedures performed by plastic surgeons on massive weight loss patients. In 2006, more than 65,000 body contouring procedures were performed.

Post–Bariatric surgery is usually performed 12 to 18 months after the weight loss procedure or when weight loss has plateaued for three to six months. The typical weight loss for Post–Bariatric patients is around 100 pounds. Although the fat is gone, the skin has been stretched so that it now forms heavy folds, and it drapes along and hangs from the body. To regain a more normal physique, Post–Bariatric patients often benefit greatly from the removal of redundant skin. The process of removing excess skin normally requires several major operations staged at least three to six months apart.

A typical sequence for body contouring surgery is:

  • 15 to 18 months after bariatric surgery: a central body lift, with liposuction of flanks and thighs;
  • Three to six months later: medial thigh lift and arm lift;
  • Three to six months later: breast reduction or augmentation with a breast lift and trunk liposuction, if needed; and
  • Three to six months later: facial rejuvenation.
  • Total: 24 to 36 months, although not all patients choose to have all of the procedures.

Each surgery usually requires hospitalization, with stays lasting up to a few days. These are lengthy procedures with lengthy recovery times, and the incisions and scars are significant. The trade–off for patients seeking improved physical appearance and the ability to fit better into clothing is significant scarring, although most patients prefer the scars to the folds of excess skin they had before.

Body contouring surgery is essential for optimal cosmetic results among massive weight loss patients. The skin by itself will never shrink to fit the shape of the slimmer body. However, patients must have realistic expectations. Even though plastic surgeons can improve the shape of the skin, we can never entirely remove all of the loose skin.

In my practice, a candidate for body contouring surgery must have a BMI of 30 or less. In other words, a candidate for surgery can be overweight, but not still obese. In a recent paper analyzing the rate of post–operative complications after panniculectomies, the authors evaluated age, BMI, American Society of Anesthesiologists (ASA) class, specimen weight, and operative duration. Only pre-surgical BMI was an independent predictor for developing post–operative complications. In another paper reviewing complications after abdominoplasties, the complication rates for patients with BMIs above 30 soar to more than 200 percent greater than the rates for overweight and normal weight patients.

While improvement in physical appearance is important to patients, improvement in the psychological outlook of most Post–Bariatric surgery patients is equally positive. For the first time, many patients feel they are part of society. Bariatric surgery patients, however, can have special psychological needs. During their years of obesity, many faced ridicule, prejudice, and rejection, leading to low self–esteem. When the weight and excess skin is no longer there, many have problems with self-identity and learning to deal with their changed life circumstances, including attention from the opposite sex, jealousy from spouses and obese friends, and interference from their own family members.

Nonetheless, despite the new issues bariatric patients may face after making the life-altering decision to have Post–Bariatric body contouring surgery, most patients report a substantial improvement in their self image and their quality of life.

References

American Society for Metabolic and Bariatric Medicine 2008 Fact sheet: Bariatric surgery. Available at http://www.asbs.org/ Newsite07/media/factsheet1_bariatric -surgery.pdf. Accessed January 5, 2008.

American Society for Plastic Surgeons 2004, Gastric bypass surgery popularity leads to jump in plastic surgery procedures, according to ASPS statistics. Press release, March 10. Available at http://www.plasticsurgery.org/ media/press_releases/Gastric-Bypass- Surgery-Popularity-Leads-to-Jump-in- Plastic-Surgery-Procedures.cfm. Accessed January 5, 2008.

Arthurs, Zachary M., Daniel Cuadrado, Vance Sohn, et al. 2006, Post–Bariatric panniculectomy: Pre-panniculectomy body mass index impacts the complication profile. Paper presented at the 93rd meeting of the North Pacific Surgical Association, Spokane, WA, November 10–11.

Centers for Disease Control and Prevention 2007, New CDC study finds no increase in obesity among adults; but levels still high. Press release, November 28. Available at http://www.cdc.gov/ nchs/PRESSROOM/07newsreleases/ob esity.htm. Accessed January 5, 2008.

Panel Report 2006, Psychological considerations of the massive weight loss patient. Plastic & Reconstructive Surgery. Body Contouring After Massive Weight Loss. 117(1) Supplement:17S-21S, January.

Pipes, Sally 2007, Brave New Diet. Washington Post, Wednesday, December 26, p. A21. Rogliani, M., E. Silvi, L. Labardi, et al. 2006, Obese and nonobese patients: Complications of abdominoplasty. Annals of Plastic Surgery 57(3):336–338, September.

Rohrich, Rod J. 2004, Obesity in America: An increasing challenge for plastic surgeons. Plastic & Reconstructive Surgery. 114(7):1889-1891, December.

Song, Angela Y., J. Peter Rubin, Veena Thomas, et al. 2006, Body Image and Quality of Life in Post Massive Weight Loss Body Contouring Patients. Obesity 14:1625–1636

Wu, June K. 2006, Body contouring after bariatric surgery is critical for optimal cosmetic results. MedGenMed 8(2):77. Available at http://www.pubmedcentral. nih.gov/articlerender.fcgi?tool=pu bmed&pubmedid=16926816. Accessed January 5, 2008.

Virginia A. Pittman–Waller, MD, MPH is a plastic surgeon in private practice in San Antonio. She received her MPH from the Yale School of Medicine and her MD from The University of Texas Medical School at San Antonio. She trained in general surgery at University Hospital in San Antonio and in the UMDNJ affiliated program at Morristown Memorial Hospital in Morristown, NJ, which has one of the largest bariatric surgery programs in the country. She completed her plastic surgery residency training in the Methodist Hospital/ St. Joseph Hospital program in Houston.

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