The Prevalence of Body Contouring Surgery After Gastric Bypass Surgery

Marijuana Use Increases the Risk of Postoperative Bleeding in Patients Undergoing Abdominal Body Contouring

BACKGROUND

The legalization and changing perception of marijuana have led to a significant increase in its use. Although studies exploring marijuana's physiological effects have grown, its effect on surgical outcomes remains unclear. This study investigates the influence of marijuana consumption on postoperative complications in patients undergoing abdominal body contouring surgeries such as abdominoplasties and panniculectomies.

METHODS

A retrospective chart review was conducted on patients who underwent abdominal body contouring procedures at an urban academic institution from 2016 to 2021. Data collected included demographic characteristics, marijuana consumption (active use, former use (last use 6 weeks prior to surgery), or never user), preoperative comorbidities, tobacco usage, operative characteristics, and postoperative complication data within 90 days.

RESULTS

A total of 815 patients were included, with 61 patients (7.5%) reporting active marijuana use, 31 patients (3.8%) reporting former marijuana use, and 723 (88.7%) reporting never using marijuana. The average age was 45.32 (SD 11.31), and the average BMI was 29.85 (SD 4.44). At the time of surgery, patients with any history of marijuana use had an increased risk of complications (OR=1.96; p = 0.006), and active marijuana users had a significantly higher risk of hematoma formation (OR = 3.02; p = 0.013).

CONCLUSIONS

Active marijuana use was significantly associated with an increased risk of postoperative hematoma formation following abdominal body contouring surgeries. These findings suggest the need for routine preoperative screening and tailored risk-reduction strategies for marijuana users.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of Medial Thighplasty on Self-Perception and Body Image After Post-Bariatric Massive Weight Loss

BACKGROUND

The demand for body sculpting procedures after massive weight loss (MWL) has grown, with medial thighplasty (MT) emerging as an effective option. This study examines the impact of MT on quality of life (QoL), particularly focusing on body image and self-perception in individuals who have undergone MWL.

METHODS

This retrospective, single-center study included 21 patients who had post-bariatric MWL and subsequently underwent MT. QoL, with a focus on body image and self-perception, and was assessed through a custom-designed questionnaire administered before and after surgery. Inclusion criteria were a BMI < 35 and a history of bariatric surgery.

RESULTS

Twenty-one patients (20 female, 1 male) were included, with an average age of 50.3 years. The median weight loss was 58.4 kg. Post-operatively, the Physical Component Score (PCS-12) showed significant improvement, while the Mental Component Score (MCS-12) did not show a notable change. However, self-acceptance, body contact, sexuality, and self-esteem all significantly improved post-surgery, whereas vitality did not.

CONCLUSIONS

Consistent with previous studies, MT yields positive outcomes regarding physical well-being. This study further highlights the procedure's benefits for self-acceptance, body contact, sexuality, and self-esteem. Patients with expectations of improvements in vitality, or mental health concerns like depression or anxiety, should be carefully selected and may benefit from multidisciplinary care, including psychiatry or psychological support, to avoid dissatisfaction with post-surgical outcomes.

Low Preoperative Albumin Levels Significantly Associated with Increased Risk of Wound Infection and Bleeding After Panniculectomy

Introduction: Panniculectomy is recognized to have a high complication rate with up to 56% of patients having postoperative wound healing problems. As they are generally elective procedures, surgeons have the chance to optimize preoperative variables. We reviewed the relationship between preoperative serum albumin and BMI with short-term postoperative panniculectomy complications. Methods: Patients undergoing panniculectomy between January 2005 and December 2019 were identified via CPT code 15830 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Multivariate logistic regression was performed on intra/postoperative bleeding and postoperative wound infection against preoperative serum albumin, diabetes status, age, body mass index (BMI), and smoking status. Odds ratios were adjusted for comorbidities. We established statistical significance at p value <0.01. Results: Out of 1472 patients, 69 sustained intra/postoperative bleeding and 31 suffered wound infection. Lower preoperative albumin levels (R2 = 16.3%, p < 0.0001) and elevated BMI (R2 = 9.4%, p < 0.0001) were both significantly associated with increased likelihood of wound infection. For every 1 g/dL decrease in albumin, patients' odds of bleeding increased 1.85 (OR = 1.85, CI 95%= [1.14-2.99]) times, and odds of wound infection increased 5.03 (OR = 5.03, CI 95%= [2.78-9.10]) times (p < 0.0001). BMI and albumin were weakly correlated (r = -0.28) suggesting each had independent effects on complications. Conclusion: In patients undergoing panniculectomy, preoperative albumin level is significantly inversely associated with postoperative bleeding and wound complications. More research is needed to evaluate whether proactively optimizing albumin may reduce complications.

The use of Fibrin Sealants in Reducing Drain Output in Abdominoplasty: Is it Useful?

Background

Abdominoplasty is a common surgical procedure in which excess abdominal skin and fat are reduced to improve body contouring. Fibrin sealant has been proposed to reduce postsurgical bleeding and exudation. In this study, we evaluated whether there was a significant statistical difference in surgical output between the use of fibrin glue and its nonuse in abdominoplasty surgery, specifically in reducing bleeding and exudation.

Material and methods

A retrospective chart review of 68 postbariatric abdominoplasty patients (58 females, 10 males) was performed. We divided the patients into Group A (30 cases, 44%), in which we used fibrin sealant, and Group B (38 cases, 56%), in which we did not use fibrin glue. We calculated the total amount of liquid in suction drainages until the day of their removal. Statistical analysis included the independent t-test with a significance level of 0.05.

Results

The average drainage output in Group A was 620.0 ± 375.0 mL, whereas in Group B, it was 500.0 ± 290.0 mL. Results indicate an insignificant correlation between the use of fibrin glue and the amount of liquid in the surgical drains (t = 1.52, p = 0.13). The result is not significant at p <.05 according to the independent t-test.

Conclusion

The use of fibrin sealant surely has a high value in all surgical branches to reduce postoperative complications, but in our study, we did not find any advantages in its use for reducing surgical drain output in abdominoplasty patients.

Ethical Considerations and Outcomes in Body Contouring Surgeries Among Adolescents: A Comprehensive Narrative Review

BACKGROUND

Body contouring surgery (BCS) in adolescents, particularly following bariatric surgery, involves a complex array of ethical, psychological, and medical factors. This review focuses on adolescents who have experienced significant weight loss, often due to bariatric surgery, and subsequently require body contouring to address excess skin and soft tissue.

METHODS

A literature narrative review was conducted using PubMed and Google Scholar databases. Relevant articles were screened and selected based on their discussion of post-bariatric and massive weight loss body contouring surgeries in adolescents, focusing on prevalence, outcomes, and ethical considerations.

RESULTS

The prevalence of BCS among adolescents is rising, influenced by social media and societal perceptions of beauty. However, the percentage of adolescents receiving BCS after bariatric surgery remains low. Adolescents undergoing BCS experience improvements in physical functioning, body image, and psychological well-being. Complications, although common, are mostly minor. Ethical considerations include ensuring informed consent, assessing emotional maturity, managing patient expectations, and involving adolescents in decision-making. Comparative analysis reveals similar outcomes in adults and adolescents, but adolescents face unique ethical challenges related to autonomy, long-term effects, and ongoing physical and emotional development.

CONCLUSION

BCS in adolescents following bariatric surgery can lead to improved physical and psychological outcomes. However, the decision to undergo BCS must be carefully considered, taking into account the adolescent's maturity, expectations, and long-term well-being. Ethical considerations are paramount, emphasizing the need for informed consent, realistic expectations, and a multidisciplinary approach. Further research is needed to assess long-term outcomes and the specific ethical implications of BCS in adolescents compared to adults.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Histological Skin Changes After Massive Weight Loss in Post-bariatric and Non-bariatric Patients

BACKGROUND

Changes in the skin structure, including the collagen and elastin content, have been reported with massive weight loss (MWL) following bariatric metabolic surgery (BMS) and have been correlated to a higher risk of complications after body-contouring surgery (BCS). This study aimed at comparing the histological characteristics of the skin of patients having surgical MWL (SMWL) post-BMS to those with non-surgical massive weight loss (NSMWL).

METHODS

This prospective study compared the epidermal thickness, and collagen and elastin fibers content in 80 skin biopsies obtained from BCS procedures performed to patients who experienced MWL defined more than 50% of excess weight loss (%EWL) either SMWL (40 biopsies) or NSMWL (40 biopsies). Twenty biopsies in each group were obtained from abdominoplasties and 20 from breast reductions. Epidermal thickness was measured in H&E-stained sections, collagen fibers were assessed using Masson trichrome-stained sections, and elastin fibers were assessed using Modified Verhoeff's stained sections. Image analysis software was used to calculate the fractions of collagen and elastin fibers.

RESULTS

This study included 77 patients, 38 SMWL patients, and 39 NSMWL patients. The SMWL group had a significantly higher age (p < 0.001), a longer time interval from intervention (p < 0.001), higher initial weight (p < 0.001), higher initial BMI (p < 0.001), lower current weight (p = 0.005), lower current BMI (p < 0.001), and significantly higher %EWL than NSMWL group (p < 0.001). No significant differences were detected between the two groups regarding complications after abdominoplasty (p = 1.000). The elastic fibers content in the dermis was significantly higher in the abdominal region of the NSMWL group than SMWL (p = 0.029). All other parameters showed non-significant differences between NSMWL and SMWL in the skin of abdomen and breast.

CONCLUSION

The SMWL group had a significant reduction in elastic fiber content in the skin of the abdomen compared to the NSMWL group. The collagen content was equally reduced in both groups with non-significant differences in both breast and abdomen regions in both groups.

Vertical Body Lift: Surgical Technique and Comparison with the Inferior Body Lift Technique

BACKGROUND

Patients with massive weight loss have excessive skin laxity along both vertical and transverse axes. Vertical body lift (VBL) is a body-contouring technique addressing both excesses, promoting not only body lifting but also a tightening effect. The aim of this study was to describe the authors' VBL surgical technique and its potential clinical applications. In addition, they present their experience among postbariatric surgery patients to compare surgical aspects and outcomes of VBL and the classic inferior body lift (IBL) technique.

METHODS

The authors reviewed data on 140 consecutive postbariatric surgery patients who underwent a body lift procedure between January of 2018 and March of 2020. The patients were divided into two groups: the VBL group and the IBL group. Patient demographics, operative details, and postoperative outcomes were compared between groups.

RESULTS

Of the 140 patients included in the study, 92 underwent IBL and 48 underwent VBL. There were no statistically significant differences between groups for surgical duration (IBL, 192 minutes; VBL, 193 minutes), hemoglobin decrease (IBL, 2.32 g/dL; VBL, 2.11 g/dL), hospital length of stay (IBL, 5.4 days; VBL, 5.7 days), or complication rate (IBL, 32%; VBL, 31%).

CONCLUSIONS

The authors' study shows comparable operative details and postsurgical outcomes between the VBL and classic IBL techniques. In their experience, VBL is a reliable and reproducible technique that can improve aesthetic and functional outcomes in a subpopulation of approximately one-third of patients with massive weight loss.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A National Analysis of Socioeconomic Variables of Access to Inpatient Body Contouring Procedures After Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery often results in excess skin, which has led to a population of patients seeking body contouring surgery (BCS). This study aimed to investigate the prevalence of patients who underwent BCS following bariatric surgery using the national inpatient sample (NIS) database and to assess the demographic and socioeconomic variables of this cohort.

METHODS

NIS database was queried from 2016 to 2019 using ICD-10 codes to identify patients that underwent bariatric surgery procedures. Patients who subsequently underwent BCS were compared to those who did not. Multivariate logistic regression was used to identify factors associated with receipt of BCS.

RESULTS

A total of 263,481 patients that underwent bariatric surgery were identified. Of those, 1777 (0.76%) patients underwent subsequent inpatient BCS. Being female was associated with greater odds of undergoing body contouring (OR 1.28 95% CI 1.13-1.46, p = 0.0001). Patients who underwent BCS were more likely to have their procedure performed in large and government-controlled hospitals than bariatric surgery-only patients (55% vs. 50%, p < 0.0001, and 11% vs. 9.4%, respectively). Higher-income did not impose higher odds of receiving BCS compared to lowest income quartile (OR 0.99, 95% CI 0.86-1.16, p = 0.99066). Lastly, compared to Medicare holders, self-payers (OR 3.5, 95% CI 2.83-4.30, p < 0.0001) or private insurance (OR 1.23, 95% CI 1.09-1.40, p = 0.001) had greater odds of undergoing BCS.

CONCLUSIONS

There is a gap in access to BCS procedures, with cost and insurance coverage being the principal barriers. Developing policies that allow for holistic evaluation of patients is crucial to improve access to these procedures.

Access to reconstructive plastic surgery for patients undergoing bariatric surgery in the Unified Health System (SUS)

INTRODUCTION

obesity is one of the most common diseases worldwide, and the most effective treatment to it is the bariatric surgery. One of the negative impacts of this procedure is the body dysmorphia caused by overhanging skin. In Brazil, the national health system - Sistema Único de Sáude (SUS) - provide body contouring surgery to treat post-bariatric patients, since 2007. This article aims to describe the Brazilian public health approach to post bariatric patients and perform an analyze in the Brazilian health care database.

METHODS

in Brazilian Health System database, a search for the post-bariatric procedures performed between 2007 to 2021 was done. The variables analyzed were geographic location, year, mean days of hospitalization, death, and mortality rate. Also, we evaluated the number of bariatric procedures done in the same period. Statistical analysis was performed using the Student-t and the chi-square tests and p-value <0.5 was considered significant.

RESULTS

a total of 12,717 plastic surgery procedures in post bariatric patients were done, with a national prevalence of 13.8%. Dermolipectomy was the most performed procedure, with 6,719. The years of 2020 and 2021 suffered a decreased of 64.3% and 70.9% in the number of surgeries (p<0,001). Bariatric Procedures had a high rate and a higher percentage of growth comparing to post bariatric surgery (p<0,001), totalizing 93,589 surgeries.

CONCLUSIONS

Brazil had a significant number of body contouring surgery, however with a low prevalence. Dermoliepctomy was the most common procedure performed. We could notice a significant impact of COVID pandemic in those procedures .

Analysis of Body Contouring and Sustained Weight Loss in a Diverse, Urban Population: A 7-Year Retrospective Review

BACKGROUND

Studies demonstrating the positive impact of body contouring on sustained weight loss in bariatric patients describe a narrow cohort. The authors sought to evaluate the impact of postbariatric body contouring procedures on sustained weight loss in minority race patients.

METHODS

A retrospective review of bariatric surgery patients at a single institution was performed. Patients were grouped as follows: (1) those who underwent body contouring, (2) those who had consultation but did not undergo body contouring, and (3) those without consultation. Body mass index (BMI) and excess body weight loss (EBWL) over 7 years were the primary outcomes.

RESULTS A TOTAL OF

2531 patients were analyzed: 350 in group 1, 364 in group 2, and 1817 in group 3. At postoperative year 7, groups 1 and 2 had average BMIs 4.71 and 2.31 kg/m 2 lower than group 3, respectively, while adjusting for covariates. After exclusion of 105 patients in group 2 who were not offered body contouring because of inadequate weight loss, however, group 2 had an average BMI 4.07 kg/m 2 lower than group 3 at postoperative year 7. During postoperative year 1, group 1 had an average EBWL of 74.38%, which declined 1.51% yearly, and group 2 had an average EBWL of 70.12%, which declined 1.86% yearly. After exclusion of the aforementioned patients, group 2 had an average EBWL of 74.9% at postoperative year 1, which declined 1.88% yearly.

CONCLUSIONS

Body contouring after bariatric surgery did not impart a clinically significant, long-term sustained weight loss benefit in the authors' cohort. In the authors' study population, patients identifying as black had significantly worse sustained weight loss.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Concurrent abdominal body contouring and hernia repair is a safe choice: An analysis of the 2015-2020 ACS-NSQIP database

BACKGROUND

Concurrent hernia repair (HR) with abdominal body contouring procedures (ABD), panniculectomy, and abdominoplasty, has been discussed as a strategy. The purpose of this study is to evaluate potential medical and surgical complications following concurrent ABD-HR, with a greater emphasis on cosmetic abdominoplasty.

METHODS

The 2015-2020 ACS-NSQIP datasets were utilized to identify patients who underwent ABD or ABD-HR. Propensity score (PS) matching was used to reduce selection bias by equating groups (ABD vs. ABD-HR) based on covariates. Bivariate analyses of independent variables by our outcomes of interest were performed using the Pearson Chi-Square and Fisher's Exact tests for categorical variables and the Wilcoxon rank-sum test for continuous variables.

RESULTS

Of the 14,115 patients identified in the ACS-NSQIP, 13,634 had ABD, while 481 had both ABD and HR. Following PS-matching of the cohorts, ABD (n = 481) and ABD-HR (n = 481), bivariate analysis of the combination of incisional, umbilical, and epigastric hernias indicated longer operative times (mean: 209.6 min) (P < 0.001) and a longer hospital length of stay (mean: 1.9 days) (P < 0.001). The incidence rate of postoperative complications such as wound dehiscence, deep venous thromboembolism, DVT, unplanned return to the OR within 30 days, and other medical complications revealed no significant differences between the two cohorts. A sub-group analysis of wound complications found no significant difference for any wound type. Analysis was also conducted for each type of hernia separately, yielding the same results.

CONCLUSION

Our results show no increase in postoperative morbidity when combining ABD and HR compared to ABD alone, suggesting that these procedures can be safely performed concurrently and regardless of the type of hernia.

SESQ, a patient-reported outcome instrument addressing excess skin; report on the updated version and the validation process

Excess skin after weight loss is perceived as a major problem for the majority of the bariatric patients, between 68 and 90% desire additional reconstructive surgery. However, only about 20% of the patients actually have the possibility to undergo these procedures. Reliable and valid patient-reported outcome instruments, PROM, are required in order to consider the patients' perspective of excess skin when discussing reconstructive surgery. The aim of this study was to present the updated version of Sahlgrenska Excess Skin Questionnaire, SESQ and to report on the validation process. The material for the process to evaluate internal consistency and known group validity was based on four different studies conducted at the Department of Plastic Surgery at Sahlgrenska University Hospital, Sweden. Internal consistency was high in all four groups examined; the normal population, the obese patients, the post-bariatric patients and the post-abdominoplasty patients. Values for Cronbach's alpha were >0.86 in all groups, and the highest value was seen in the obese patients (0.92). Furthermore, regarding known group validity, there were strong significant differences between the answers from the normal population in comparison with most of the other studies. In conclusion, patients thought that the questions in SESQ were easy to understand, that they covered all appropriate aspects of excess skin and the patients did not think that SESQ overlooked any questions or aspects concerning excess skin. SESQ is a valid questionnaire addressing excess skin in post-bariatric patients. The updated version of the SESQ is both accurate and user-friendly.

Physical activity with hindrances: a qualitative study of post bariatric patients' experiences of physical activity in relation to excess skin

A common side effect after massive weight loss is excess skin. Knowledge about the experience of excess skin in relation to physical activity is limited. The aim of this study was therefore to investigate how post bariatric surgery patients experience physical activity in relation to excess skin. Fifteen semi-structured interviews were performed with individuals who experienced excess skin after massive weight loss after bariatric surgery. The interviews were transcribed, and data were analyzed by qualitative content analysis. An overall theme emerged, that the body was still a hindrance for physical activity but now because of excess skin. There were major changes in the participants' ability to be active after the weight loss, but there were still obstacles and some of them remained from the time when they were obese. The analysis resulted in three main categories containing the participants' knowledge about, changes in and wishes for physical activity after weight loss, factors that affected the ability and the role of mental processes. The result contributes to increased knowledge about post bariatric patients' experiences of excess skin in relation to physical activity. After weight loss, the body was still a hindrance for physical activity but now because of excess skin. As physical activity is important for general health, excess skin inhibiting physical activity ought to be an indicator for reconstructive surgery.

Depressive symptoms before and after abdominoplasty among post-bariatric patients - a cohort study

The majority of post-bariatric patients suffer from excess skin after weight loss, impairing physical, psychosocial and mental health. The abdomen is the most common location for excess skin, and abdominoplasty is the most commonly required reconstructive procedure. Abdominoplasty removes excess abdominal skin and attenuates related symptoms, but knowledge regarding mental health-related effects is scarce. Here, we aimed to evaluate the symptoms and severity of depression before and after abdominoplasty in post-bariatric patients and to analyse the relationships between depressive symptoms, quality of life (QoL) and experience of excess skin. We enrolled 110 former obese patients undergoing abdominoplasty. Three questionnaires evaluating the symptoms of depression (Beck Depression Inventory (BDI-II)), experience of excess skin (Sahlgrenska Excess Skin Questionnaire (SESQ)) and QoL (36-item Short-Form Health Survey (SF-36)) were completed preoperatively and 1 year postoperatively. After abdominoplasty, symptoms of depression (BDI sum score) significantly decreased (5.8 vs. 3.0, p = .037). Scores on three BDI questions improved (p < .05), and the SESQ score normalised (p < .001), while the SF-36 score was unaffected. The BDI sum score was moderately correlated with the SF-36 mental composite score (preoperatively, r_s = -0.69; postoperatively, r_s = -0.66) and fairly correlated with the SF-36 physical composite score (r_s = 0.32, r_s = 0.26). The correlation between the BDI sum and SESQ scores was poor preoperatively (r_s = -0.106) and fair postoperatively (r_s = 0.232). The results indicate that abdominoplasty may reduce symptoms of depression in post-bariatric patients. However, the procedure did not affect SF-36 scores. Further studies are required to validate these results.

Actualized lower body contouring surgery after bariatric surgery - a nationwide register-based study

Massive weight loss might lead to excess skin folds causing functional, physical, and psychosocial discomfort. Following bariatric procedures, an increasing number of patients are seeking lower body contouring surgery (LBCS). The proportion of bariatric patients who undergo LBCS is largely unknown. The aim of this current study was to analyse the incidence and realization of LBCS in bariatric patients in Finland.National retrospective register linkage study including all adult patients who received bariatric surgery in Finland during 1998-2016. The data were obtained from the Finnish national health registers maintained by the Finnish Institute for Health and Welfare. Altogether 1089 (14.1%) of 7703 bariatric patients underwent LBCS during the study period. The majority of the LBCS procedures were abdominoplasty (89%). Median latency between bariatric surgery and LBCS was 31 months. The patients with LBCS were younger (p < 0.001) and received sleeve gastrectomy (p < 0.001). We revealed an annual correlation between LBCS and bariatric procedures (r = 0.683). With a two-year latency between the bariatric and post-bariatric operations, the correlation co-efficiency was strong (r = 0.927). LBCS operations ranged from 5 to 215 per hospital district. Most LBCSs (97.3%) were performed in public hospitals, and some (41%) were performed in university hospitals. This study shows that only 14.1% of bariatric patients undergo LBCS. There is a correlation between bariatric procedures and succeeding plastic surgical reconstructive procedures.

Comparing Bariatric Surgery Patients Who Desire, Have Undergone, or Have No Desire for Body Contouring Surgery: a 5-Year Prospective Study of Body Image and Mental Health

PURPOSE

After bariatric surgery, body contouring surgery (BCS) is thought to improve body image, weight loss, and mental health. Many patients desire but do not undergo BCS after bariatric surgery. This patient subset has rarely been studied. The present study compares bariatric surgery patients that, at 5 years after surgery, desires, have undergone or have no desire for BCS regarding pre- and post-surgery body image and mental health, including within-group changes over time.

MATERIALS AND METHODS

Data were collected from participants (N = 216) pre-bariatric surgery and at 1- and 5-year post-surgery. Health care providers measured body mass index (BMI). All other data were collected via self-report (questionnaires).

RESULTS

At 5-year post-surgery, 30.6% had undergone BCS, 17.1% did not desire it, and 52.3% desired BCS. Patients who subsequently desired BCS scored lower on body satisfaction pre-surgery than the other groups. They also reported less resilience pre-surgery and more depressive symptoms at all times compared to participants with BCS. For five-year post-surgery, patients who desired BCS had lower body satisfaction levels than patients with BCS and were more bothered with excess skin relative to the two other groups. Body satisfaction improved in all three groups from baseline to five years and in most patients with BCS. Mental health improved only in patients with BCS.

CONCLUSION

This study emphasizes the relevance of identifying participants who desire but have not undergone BCS. The study suggests that BCS is associated with improved body image and mental health.

The Three-Hour Lower Body Lift: Evolution of a Technique and Personal Experience after 155 Consecutive Cases

BACKGROUND

Body-contouring is a surgical field in growing demand, as the number of massive weight loss patients following bariatric surgery is increasing. The purpose of this study was to provide a straightforward and time-efficient circumferential body lift technique to achieve optimal lower truncal contouring.

PATIENTS AND METHODS

A total of 155 massive weight loss patients (133 women and 22 men) underwent lower body lift surgery between 2006 and 2018. The mean preoperative weight reduction and body mass indices were 56.5 ± 16.6 kg and 26.7 ± 4.7 kg/m2, respectively. The preoperative markings focused on the back and gluteal region, and the modified surgical technique are described. Additionally, improvements of intra-operative repositioning of the patient and how to deal with sterilization and dressings are elucidated.

RESULTS

The average intra-operative time was 178 ± 54.6 minutes. The mean follow-up of all patients was 8.2 ± 2.4 years. The most common complications were related to wound dehiscence (n = 38) and seroma (n = 18). The mean weight of the resected tissue was 3 056 ± 1 816.5 g.

CONCLUSION

The lower body lift represents an effective and safe body contouring procedure to treat massive weight loss patients with multiple regions of concern. The current study describes a modified surgical technique that reduces operating time and complications, notably.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

[Lipoabdominoplasty in post-bariatric Surgery: a relevant Alternative to Fleur-de-Lis abdominoplasty?]

BACKGROUND

The number of bariatric procedures, and thus also the number of post-bariatric operations, has increased dramatically in recent years. Although long scars are common in post-bariatric surgery and accepted in favour of body shape reconstruction, we increasingly notice the wish for aesthetically pleasing results in addition to the desire for body contouring. In particular, Fleur-de-Lis abdominoplasty (FdL) is viewed critically by younger patients after massive weight loss due to the visible vertical scar. Surgeons are also often bothered by the unsatisfying aesthetic outcome as well as the higher rate of complications.

METHODS

Retrospective analysis of 20 female patients with massive weight loss following bariatric surgery, who received lipoabdominoplasty instead of Fleur-de-Lis abdominoplasty in the period from January 2019 to June 2020. Data analysis was based on measurements of preoperative vertical and horizontal excess skin and fat (Pittsburgh Rating Scale), Body Mass Index, surgical technique and final result.

RESULTS

Twenty female patients with an indication for FdL abdominoplasty underwent radical liposuction of the abdomen combined with abdominoplasty. The original weight before massive weight reduction ranged between 100 and 168 kg. Average weight reduction was 56.5 kg. The mean BMI was 27.3 kg/m². The average age of our cohort was 40 years. One patient (5 %) had a major complication. This was an infected seroma which could be treated conservatively. Two other patients (10 %) developed an uninfected seroma as a minor complication.

CONCLUSION

Our work shows that lipoabdominoplasty can be performed safely and well even in patients after massive weight loss. It is possible to achieve good body contours without vertical incisions and with a high degree of patient satisfaction. The number of patients who have to undergo FdL abdominoplasty can be successfully reduced by this technique.

Sociodemographic characteristics of patients and their use of post-bariatric contouring surgery in the US

BACKGROUND

Expansion of healthcare insurance coverage to bariatric surgeries has led to an increased demand from patients for post-bariatric contouring surgeries. This study examined the relationship between the use of contouring procedures on post-bariatric surgery patients, clinical need and sociodemographic factors.

METHODS

Data were extracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Ambulatory Surgery Sample (NASS) regarding hospital-owned ambulatory surgical centres in the US. Episodes without missing values relating to patients, 18 years old or above were the primary unit of analysis. Episodes were excluded if the field regarding expected payer was reported as "no charge." The primary outcome was the likelihood of panniculectomy, abdominoplasty, and mastopexy among post-bariatric surgery patients; and the degree to which uptake of these types of contouring surgery were associated with age, gender, median households' income, expected payer, patient's location, and comorbidity.

RESULTS

A total of 66,368 weighted episodes of care received by patients who had had bariatric surgery were extracted (54,684 female [82.4%]; mean age, 51.3 [SD, 12.1]; 6219 episodes had contouring surgeries [9.37%]). Panniculectomy was the most common post-bariatric contouring procedure (3.68%). Uptake of post-bariatric contouring procedures was associated with age, sex, payment type, area-based measures of median household income, and patient location. Compared to Medicare insured patients, the odds of receiving contouring surgery among self-payers were 1.82 (95% CI, 1.47 to 2.26) for panniculectomy, 14.79 (95% CI, 12.19 to 17.93) for abdominoplasty and 47.97 (95% CI, 32.76 to 70.24) for mastopexy. Rank order of comorbidity profiles also differed between insured and self-paying recipients of contouring surgery.

CONCLUSIONS

Insurance status of bariatric surgery patients and their sex were strongly associated with receipt of a range of contouring procedures. Self-payments were associated with a doubling of the odds of having panniculectomy and an increase in the odds to approximately 14 times for abdominoplasty and 48 times for mastopexy. Thus, access to contouring surgery by post-bariatric patients may be disproportionately dependent on personal preference supported by ability to pay rather than clinical need. Further research is needed to examine the impact of contouring or delayed/denied contouring on health status.

The Age Factor in Postbariatric Body Contouring Surgery Outcome

BACKGROUND

Increasing life expectancy will likely lead greater numbers of older patients to seek postbariatric body contouring plastic surgery. The impact of age on body contouring plastic surgery outcome is undetermined.

METHODS

A retrospective cohort study of 317 postbariatric body contouring plastic surgery cases was performed. Patient demographics and operative and postoperative data were collected. Patients were categorized into three age groups, and univariate analysis examined group differences. Multivariate logistic regression analysis assessed independent associations between age and surgical outcome measures.

RESULTS

Patients 60 years and older had a higher mean preoperative body mass index (30.8 ± 3.6 kg/m2, p < 0.001) and higher rates of hypertension (48.9 percent, p < 0.001), dyslipidemia (38.3 percent, p < 0.001), and diabetes mellitus (17 percent, p = 0.012) compared to the younger age groups. They also sustained significantly higher complication rates (any minor complications, p = 0.004; minor surgical site infections, p = 0.005; minor hematomas, p = 0.007; any major complications, p < 0.001; major surgical-site infections, p < 0.001; and major dehiscence, p < 0.001). Increasing age was a significant risk factor for any major complications (p = 0.005), reoperation (p = 0.02), and readmission (p = 0.001). Age greater than or equal to 60 years was a significant risk factor solely for readmission (OR, 3.32; p = 0.03).

CONCLUSIONS

Increasing age was a risk factor for adverse postoperative outcome in postbariatric body contouring plastic surgery patients; however, age greater than or equal to 60 years in and of itself was an independent risk factor for readmission only. These findings may aid plastic surgeons in patient consultation and in decision making regarding suitable candidates for these procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

A Comparative Analysis of Fleur-de-Lis and Traditional Panniculectomy after Bariatric Surgery

INTRODUCTION

The Fleur-de-Lis panniculectomy (FdL) adds a vertical component to correct complex contour deformities after massive weight loss by addressing supra-umbilical horizontal skin excess which is not addressed with infra-umbilical transverse panniculectomy (TP). We aim to perform a head-to-head comparison of clinical outcomes and patient reported outcomes (PROs) between FdL and TP.

METHODS

A retrospective review of patients ≥18 with a history of bariatric surgery undergoing FdL or TP by a single plastic surgeon between 07/01/2015 and 05/31/2020 was conducted. Surgical site occurrences (SSOs) including surgical site infection (SSI), delayed healing, cellulitis, seroma, hematoma, surgical site occurrences requiring procedural intervention (SSOpi), and a composite of other postoperative outcomes were assessed. In addition, patient satisfaction was analyzed using the Body-Q questionnaire across 12 domains.

RESULTS

The analysis included 56 patients; 26 and 30 patients who were treated with FdL and TP, respectively. Cohorts were statistically similar in terms of age, gender, BMI, and co-morbid conditions. The overall complication rate was 50% (FdL n = 14 (53.9%), TP n = 14 (46.7%); p = 0.592). On multivariate analysis, pannus weight was associated with the development of SSO (p = 0.04). FdL incision, however, was not an independent risk factor for adverse outcomes. Absolute improvement in PROs was similar in both cohorts across multiple domains.

CONCLUSION

FdL showed a comparable safety and efficacy profile to TP when performed in post-bariatric surgery patients, with equivalent improvement in PROs across multiple domains. Preoperative weight loss should be encouraged in this population as pannus weight is an independent risk factor for complications.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Is body-contouring surgery a right for massive weight loss patients? A survey through the European Union National Health Systems

Background

Obesity is pandemic nowadays, and hanging skin with consequent functional and psychological impairments is a common price to pay for massive weight loss. Plastic surgery in postbariatric patients represents a fundamental step to regain possession of a positive self-image. The authors aimed to investigate how EU countries’ National Health System (NHS) behaves regarding reimbursements for body-contouring procedures after massive weight loss.

Methods

A 1-item survey was sent to contacts found on the NHS official Web sites of 27 EU countries. The question focused on postbariatric surgery practice and investigated the accessibility criteria for NHS coverage concerning body-contouring procedures after massive weight loss.

Results

Responses were collected between January 2020 and February 2020. Response rate was 65%, and access criteria to NHS coverage for postbariatric surgery presented great variation across EU countries. Only one country presented an NHS with no coverage for postbariatric surgeries.

Conclusions

Despite the conspicuous variability found among the EU NHS, none of them admit reimbursement in cases of merely aesthetic procedures: postbariatric patients need to display functional or health impairments due to the extensive weight loss. The results of the current study describe a complex situation among EU countries, but a common lead towards postbariatric patients’ care shows off. The ultimate goal of bariatric patient’s healing should be full restoration of physical and psychological well-being. NHS of EU countries are facing this increasing request in various ways, and more studies should be performed in order to understand which is the best approach.

Level of evidence: Not ratable.

Panniculectomy Outcomes by Body Mass Index: an Analysis of 12,732 Cases

Purpose

With an increasing rate of obesity in the USA, bariatric surgery has become widespread, resulting in a greater number of patients seeking panniculectomy. The authors aim to determine the complication profile of panniculectomies by body mass index (BMI).

Methods

The 2012–2018 National Surgical Quality Improvement Program database was queried for all panniculectomy cases. Patients were assigned to a category by their calculated BMI. Rates of complications were compared across BMI ranges. Demographics, comorbidities, and perioperative factors were compared between those with and without complications. Multivariable analyses were performed to analyze the associations between BMI ranges and post-surgical complications.

Results

Twelve thousand seven hundred thirty-two cases were analyzed, of which 1759 (13.8%) had at least one postoperative complication. As BMI increased, patients were more likely to experience postoperative complications (p<0.001). Patients experiencing complications were more likely to be male, older, of a higher BMI group, have a higher American Society of Anesthesiologists Personal Status classification, be an inpatient, have various comorbidities, or be undergoing a concurrent procedure. On multivariable analysis, patients who were overweight (OR=1.24, p=0.039), with class 1 (OR=1.72, p<0.001), class 2 (OR=2.10, p<0.001), or class 3 (OR=3.01, p<0.001) obesity were more likely to have a postoperative complication. Wound complications were particularly prevalent in patients who were overweight (OR=1.77, p=0.001) or with class 1 (OR=2.59, p<0.001), class 2 (OR=4.05, p<0.001), or class 3 (p=5.84, p<0.001) obesity compared to non-overweight patients.

Conclusion

A higher BMI is associated with more postoperative complications, particularly wound healing complications, following panniculectomy in a dose-dependent manner.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05468-w.

Body Contouring Surgery Improves Weight Loss after Bariatric Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Our main objective is to evaluate the effect of body contouring surgery (BCS) on the magnitude and durability of weight loss after bariatric surgery.

METHODS

Medline, EMBASE, Cochrane, and Scopus search were conducted from the time of their inception to June 2020. We included comparative studies that assessed weight progression, in terms of Body Mass Index change (∆BMI), Total Body Weight Loss (TBWL%), and Excess Weight Loss (%EWL) for the post-bariatric patient population and the effect of BCS on weight progression.

RESULTS

Eleven articles were included. The pooled sample size was 2307, of which 691 were cases who underwent BCS post-bariatric surgery, and 1616 were comparative controls. The mean follow-up time for cases and controls were 61.6 ± 23.8 months and 52.2 ± 23.8 months, respectively. Nine studies reported results of BMI changes, six provided %EWL, and five used %TBWL. Significant improvement in weight loss was observed in the BCS group when measured by either ∆BMI (3 kg/m2 points decrease, p 0.023), %TBWL (6% increase, P < 0.0001), or %EWL (14% increase, P < 0.0001). Sub-group analysis showed that increased follow-up time was associated with higher TBWL% (p 0.02).

CONCLUSION

The evidence provided in this review strongly supports the added long-term benefits of body contouring surgery for selected patients after massive weight loss following bariatric surgery. Having a multidisciplinary team that involves a bariatric and a plastic surgeon as well as nutritionists and psychologists for the management of patients with obesity going through the bariatric pathway is recommended.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Health technology assessment through the six sigma approach in abdominoplasty: Scalpel vs electrosurgery

Abdominoplasty is a surgical procedure conducted to reduce excess abdominal skin and fat and improve body contouring. Despite being commonly performed, it is associated with a risk of complications such as infection, seroma, haematoma and wound dehiscence. To reduce the incidence of complications, different methods are used to create the abdominal flap, i.e., incision with a scalpel or electrosurgery. In this study, health technology assessment (HTA) using the Six Sigma methodology was conducted to compare these incision techniques in patients undergoing abdominoplasty. Two consecutively enroled groups of patients (33 in the scalpel group and 35 in the electrosurgery group) who underwent surgery at a single institution, the University of Campania "Luigi Vanvitelli", were analysed using the drain output as the main outcome for comparison of the incision techniques. While no difference was found regarding haematoma or seroma formation (no cases in either group), the main results also indicate a greater drain output (p-value<0.001) and a greater incidence of dehiscence (p-value=0.056) in patients whose incisions were made through electrosurgery. The combination of HTA and the Six Sigma methodology was useful to prove the possible advantages of creating skin incisions with a scalpel in full abdominoplasty, particularly a significant reduction in the total drain output and a reduction in wound healing problems, namely, wound dehiscence, when compared with electrosurgery, despite considering two limited and heterogeneous groups.

A systematic review of body contouring surgery in post-bariatric patients to determine its prevalence, effects on quality of life, desire, and barriers

Many post-bariatric patients have impaired health-related quality of life (HRQoL) due to excess skin following weight loss; however, it is inconclusive whether body contouring surgery (BCS) improves this impairment. We aimed to comprehensively summarize existing evidence of the effect of BCS on the HRQoL (primary outcome) and determine the prevalence of, the desire for, and barriers to BCS (secondary outcomes). Randomized controlled trials, cohort, cross-sectional, case-control, and longitudinal studies were systematically searched in PubMed, Embase, the Cochrane Central, and Web of Science. After screening 1923 potential records, 24 studies (representing 6867 participants) were deemed eligible. Only 18.5% of respondents from cross-sectional studies underwent BCS, with abdominal BCS as the most common procedure. Most participants desired BCS but listed "cost" and "lacking reimbursement" as the main barriers. Results suggest that most post-bariatric patients who underwent BCS experienced improvements in their HRQoL, which could be seen in almost every dimension evaluated, including body image and physical and psychosocial functions. Therefore, both bariatric and plastic surgeons should regard BCS not only as an aesthetic supplement but also as a vital part of functional recovery in the surgery-mediated weight loss journey and, thus, provide it to more post-bariatric patients.

The Influence of Body Contouring Surgery on Weight Control and Comorbidities in Patients After Bariatric Surgery

Introduction

A considerable number of patients experience some long-term weight regain after bariatric surgery. Body contouring surgery (BCS) is thought to strengthen post-bariatric surgery patients in their weight control and maintenance of achieved improvements in comorbidities.

Objectives

To examine the impact of BCS on long-term weight control and comorbidities after bariatric surgery.

Methods

We performed a retrospective study in a prospective database. All patients who underwent primary Roux-en-Y gastric bypass (RYGB) and presented for preoperative consultation of BCS in the same hospital were included in the study. Linear and logistic mixed-effect model analyses were used to evaluate the longitudinal relationships between patients who were accepted or rejected for BCS and their weight loss outcomes or changes in comorbidities.

Results

Of the 1150 patients who underwent primary RYGB between January 2010 and December 2014, 258 patients (22.4%) presented for preoperative consultation of BCS. Of these patients, 126 patients eventually underwent BCS (48.8%). Patients who were accepted for BCS demonstrated significant better ∆body mass index (BMI) on average over time (− 1.31 kg/m²/year, 95% confidence interval (CI) −2.52 − −0.10, p = 0.034) and percent total weight loss (%TWL) was significantly different at 36 months (5.79, 95%CI 1.22 – 10.37, p = 0.013) and 48 months (6.78, 95%CI 0.93 – 12.63, p = 0.023) after body contouring consultation. Patients who were accepted or rejected did not differ significantly in the maintenance of achieved improvements in comorbidities.

Conclusion

BCS could not be associated with the maintenance of achieved improvements in comorbidities after bariatric surgery, whereas it could be associated with improved weight loss maintenance at 36 and 48 months after body contouring consultation. This association should be further explored in a large longitudinal study.

Evaluating the need for dermatological care in a postsurgical bariatric sample

BACKGROUND

Bariatric surgery rates are increasing in tandem with obesity in the United States. patients after surgery bariatric can lose up to or more than one-third of their excess weight within the first year. This sudden loss of weight can lead to skin redundancy and increased susceptibility to dermatological issues. There is a paucity of literature addressing the issue of skin redundancy and associated factors following bariatric surgery.

OBJECTIVES

To evaluate the prevalence and severity of dermatological concerns among postbariatric surgery patients and assess the impact of these issues on patients' quality of life.

SETTING

Surgical Weight Loss Clinic at an academic medical center in south-central Pennsylvania.

METHODS

A cross-sectional survey was administered from September 9 to November 30, 2020 to adult postoperative patients. Data were collected via self-report questionnaires with a retest issued approximately 72 hours later. The survey included questions regarding occurrences of skin disturbances and the Dermatology Life Quality Index. All analyses were conducted using SAS version 9.4.

RESULTS

A total of 575 patients were invited to participate, with 103 participating and 69 completing the retest. The health questionnaire indicated that 69.6% of patients had challenges with skin rashes or irritation due to loose skin; 80.6% were interested in having skin removal surgery; and only 5.8% were referred to a dermatologist for their concerns.

CONCLUSION

The presence of skin concerns was associated with impaired HRQOL among postbariatric patients. This suggests a need to further educate the bariatric interdisciplinary team to evaluate the impacts of skin pathology on postbariatric patients.

Health-related quality of life in patients having undergone abdominoplasty after massive weight loss

BACKGROUND

Due to lack of validated body contouring-specific patient-reported outcome (PRO) instruments, the outcomes of abdominoplasty after massive weight loss have been evaluated rather rarely and mainly using generic health-related quality of life (HRQoL) instruments. The aim of the current study was to examine, using body contouring-specific (BODY-Q) and generic (15D) HRQoL instruments, the HRQoL, and key factors related to HRQoL among patients having undergone massive weight loss and abdominoplasty.

METHODS

Altogether 52 patients who underwent abdominoplasty due to massive weight loss completed the BODY-Q and the 15D HRQoL instruments. The 15D scores were compared to those of age-, gender-, and BMI-adjusted control sample of the general population.

RESULTS

The mean score of the BODY-Q Abdomen scale was 50.7 out of 100 (SD 24.4). The HRQoL of abdominoplasty patients was lower than that of age-, gender-, and BMI-adjusted general population (p = 0.001). Sleeping, discomfort and symptoms, depression, excretion, and sexual activity were the patients' main concerns. Body image and psychological well-being were strongly associated with the perceived HRQoL. The satisfaction with appearance of the abdominal area was not associated with generic HRQoL.

CONCLUSIONS

The HRQoL of abdominoplasty patients is lower than that of general population with similar age, gender and BMI. The most important factors associated with the HRQoL of the patients were body image, psychological well-being, and physical function.

Modified Frailty Index Predicts Postoperative Complications following Panniculectomy in the Elderly

Due to the high complication rate of panniculectomies, preoperative risk stratification is imperative. This study aimed to assess the predictive value of the 5-item modified frailty index (mFI-5) for postoperative complications in the elderly following panniculectomy.

The PRS Rainbow Classification for Assessing Postbariatric Contour Deformities

Supplemental Digital Content is available in the text.

Background:

There is a need for a reliable classification system to grade contour deformities and to inform reimbursement of body contouring surgery after massive weight loss. We developed the PRS Rainbow Classification, which uses select photographs to provide standardized references for evaluating patient photographs, to classify contour deformities in postbariatric patients. To assess the reliability of the PRS Rainbow Classification to classify contour deformities in massive weight loss patients.

Methods:

Ten independent experienced plastic surgeons, 7 experienced medical advisors of the healthcare insurance company, and 10 laypersons evaluated 50 photographs per anatomical region (arms, breast, abdomen, and medial thighs). Each participant rated the patient photographs on a scale of 1–3 in an online survey. The inter-observer and the intra-observer reliabilities were determined using intra-class correlation coefficients (ICCs). The ICC analyses were performed for each anatomical region.

Results:

Inter-observer reliability was moderate to good in the body regions “arms,” “abdomen,” “medial thighs,” with mean ICC values of 0.678 [95% confidence interval (CI), 0.591–0.768], 0.685 (95% CI, 0.599–0.773), and 0.658 (95% CI, 0.569–0.751), respectively. Inter-observer reliability was comparable within the 3 different professional groups. Intra-observer reliability (test–retest reliability) was moderate to good, with a mean overall ICC value of 0.723 (95% CI, 0.572–0.874) for all groups and all 4 body regions.

Conclusions:

The moderate to good reliability found in this study validates the use of the PRS Rainbow Classification as a reproducible and reliable classification system to assess contour deformities after massive weight loss. It holds promise as a key part of instruments to classify body contour deformities and to assess reimbursement of body contouring surgery.

Excess skin problems among adolescents after bariatric surgery

BACKGROUND

Bariatric surgery results in significant and durable weight loss and improved health in severely obese adolescents. An important adverse consequence of the massive weight loss after bariatric surgery is excess skin and soft tissue. The prevalence and clinical characteristics of excess skin-related symptoms have been described in adults undergoing bariatric surgery but not in adolescents. Although the higher skin elasticity of adolescents may result in fewer excess skin problems compared with adults, this hypothesis remains untested.

OBJECTIVES

The purpose of the present study was to describe the natural history of excess skin and its associated complications among severely obese adolescents undergoing bariatric surgery.

SETTING

University Hospitals, United States.

METHODS

We evaluated data from the Teen-Longitudinal Assessment of Bariatric Surgery cohort, a prospective, multiinstitutional study of adolescents (13-19 yr) undergoing bariatric surgery. Abdominal pannus severity (graded 0-5) and excess skin symptoms were evaluated preoperatively and for the first 5 years after bariatric surgery.

RESULTS

Among the 217 study participants, 198 (90%) had an abdominal pannus and 16 (7%) reported pannus-related symptoms at the time of bariatric surgery. Preoperative symptoms included intertriginous infections (n = 12, 75%), recurrent cellulitis (n = 5, 31%), and superficial cutaneous ulcerations (n = 1, 6%). Participants with a higher pannus grade preoperatively experienced both a greater reduction in pannus severity (P < .0001) and a higher incidence of pannus-related symptoms (P = .002) postoperatively. Changes in pannus severity occurred during the first 24 months after bariatric surgery; mean pannus severity remained unchanged beyond 24 months.

CONCLUSIONS

Severely obese adolescents who undergo bariatric surgery often present with an abdominal pannus at the time of surgery with associated symptoms. Higher preoperative pannus grade is associated with more pannus related symptoms after surgery. Counseling about need for body contouring surgery should be considered in this group.

Impact of Lipo-Body Lift Compared to Classical Lower Body Lift on Postoperative Outcome and Patient's Satisfaction: A Retrospective Study

INTRODUCTION

Lately, the growing number of bariatric procedures performed each year led to an increasing demand for lower trunk reconstruction. Our team previously described the lipo-body lift (LBL) technique into lower duration of drainage and therefore seromas and other complications. In this study, we compared the classical body lift (CBL) technique to the LBL procedure.

MATERIALS AND METHODS

All patients who underwent a LBL or CBL after massive weight loss between November 2012 and October 2017 were included. Surgery outcome parameters were collected as well as patient satisfaction through a satisfaction score realized at least after 1 year postoperative. Comparisons between CBL and LBL were conducted to assess the surgery's safety and the patient's satisfaction.

RESULTS

A total of 130 patients were included, 61 patients who had a LBL were compared to 69 patients who had a CBL. The mean patient age was 39.64 ± 9.97 (21-66) years old, the mean body mass index before plastic surgery was 26.83 ± 3.08 kg/m² (19.83-32.69), and the average weight loss was 53.40 ± 17.37 kg. The two groups had comparable preoperative data. Duration of drainage and hospital stay was significantly lower in the LBL group than in the CBL (p < 0.0001 and p < 0.0001, respectively). Surgical outcomes were comparable between groups as well as patient satisfaction scores.

CONCLUSION

Lipo-body lift allows early discharge of the patient by reducing the duration of drainage without increasing the risk for complications. In our opinion, this technique should be used for type 1 and 2 patients with no contraindication for abdominal liposuction.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Review of Insurance Coverage for Abdominal Contouring Procedures in the Postbariatric Population

BACKGROUND

Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population.

METHODS

The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage.

RESULTS

Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415).

CONCLUSIONS

For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.

Advanced Age Is a Risk Factor for Complications Following Abdominal Panniculectomy

BACKGROUND

Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated.

METHODS

The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders.

RESULTS

Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications.

CONCLUSION

Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

Knowledge is power: Providing previsit insurance coverage information of body contouring procedures to improve understanding and satisfaction in the massive weight loss patient

INTRODUCTION

Because of the prevalence of obesity worldwide, the rates of bariatric surgery are increasing. Bariatric surgery is covered by insurance; however, often, a surgery to correct massive weight loss surgeries is not covered despite patient perception.

METHODS

One hundred patients were identified by their initial visit to the institutional Life After Weight Loss center. Fifty of them were randomized into receiving previsit educational materials about their individual insurance plans. All the patients were surveyed to assess whether this education improved their understanding and overall consultation experience.

RESULTS

Although a majority of patients believed "panniculectomy" would be covered by insurance, most subjects overestimated insurance coverage for other procedures. Nearly all respondents (93.8%) agreed that previsit educational material improved their understanding and the satisfaction of the visit.

CONCLUSION

Many patients believe body contouring procedures to be covered by insurance, although most are not. By providing patients with their individualized insurance plans, patients report improved understanding and overall satisfaction with the consultation.

A Review of National Insurance Coverage of Post-bariatric Upper Body Lift

INTRODUCTION

Recent years have seen an increased utilisation of upper body lift following massive weight loss. Although it is typically considered cosmetic, the recurrent skin conditions and decline in quality of life may warrant medical necessity. We evaluated current insurance coverage and characterised policy criteria for upper body lift in the post-bariatric population.

METHODS

We defined upper body lift as a combination of mastopexy and upper back excision (UBE) and conducted a cross-sectional analysis of US insurance policies. Insurance companies were selected based on their enrolment data and market share. A web-based search and telephone interviews were conducted to identify the policy. Criteria were abstracted from the publicly available policies that offered coverage.

RESULTS

Of the 56 insurance companies assessed, 5% would consider coverage of both procedures. Although fewer companies held established policies for UBE than mastopexy in the post-bariatric population (79% vs 96%, p = 0.0081), there were significantly more policies that offered pre-approval for UBE than for mastopexy (30% vs 5%, p = 0.0017). Three medical necessity criteria were common to both procedures: evidence of functional impairment, secondary skin conditions, and medical photographs.

CONCLUSION

Policy criteria for coverage of mastopexy or UBE differ greatly between companies. Further evaluation of medical necessity criteria for post-bariatric mastopexy and UBE with the establishment of a standardised guideline is needed. We propose a comprehensive list of reporting recommendations to help optimise authorisation of upper body lift in the post-bariatric population, and we urge plastic surgeons to challenge current definition of "cosmetic" by insurance companies.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abdominoplasty after bariatric surgery: comparison of three different techniques

BACKGROUND

Abdominoplasty after massive weight loss is not a cosmetic procedure. The aim of this study was to compare three different techniques for postbariatric abdominoplasty.

METHODS

All postbariatric patients that have undergone abdominoplasty from January 2013 to December 2016 were included in the study. Patients were divided into 3 groups: subjects who underwent standard procedure were allocated ingroup A; those cases performed using a synthetic glue were assigned to group B; cases performed with an energy device were inserted in group C. Operative time, length of stay and complications were recorded.

RESULTS

Seventy-one abdominoplasties were performed in the selected period. Mean operative time was shorter (P<0.01) in group C (94.3±2.7 minutes) than in group A (112.1±16.8 minutes) and in group B (121±13.2 minutes). Mean length of stay was significantly reduced (P<0.01) in group C (2.4±0.7) when compared to group A (3.5±0.6 days) and group B (3.1±0.5 days). Bleeding occurred in 21 (29.5%) patients (15 in group A, 4 in groupB, 3 in group C; P<0.01). Seroma was detected in 22(30.9%) subjects (14 in group A, 2in group B, 6 in group C; P<0.01). Wound dehiscence and umbilical necrosis were recorded in 7 (9.9%) and 9 (12.6%) patients respectively, without statistical differences.

CONCLUSIONS

Both synthetic glue and energy device improve outcomes of postbariatric abdominoplasties. The glue reduces rates of bleeding and seroma. The energy deviceimproves intraoperative hemostasis and shortens operative time.

Body Contouring Surgery after Massive Weight Loss: Excess Skin, Body Satisfaction, and Qualification for Reimbursement in a Dutch Post-Bariatric Surgery Population

BACKGROUND

Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post-bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post-bariatric surgery population.

METHODS

Post-bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body.

RESULTS

A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the "desire" population; 44.1 percent of these patients met the weight criteria.

CONCLUSIONS

Post-bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.

Sublay or onlay incisional hernia repair along with abdominoplasty: which is better? Long-term results

PURPOSE

Estimation and comparison of results after incisional hernia repair (IHR) modo onlay or sublay with abdominoplasty in patients who lost the weight following Roux-en-Y Gastric Bypass (RYGB). Analysis and comparison of changes in quality of life (QL) of these patients prior to RYGB, before and after simultaneous IHR and abdominoplasty.

METHODS

Clinical analysis involved 40 patients with abdominal disfigurement (following RYGB and massive weight loss) after one-time IHR sublay method with abdominoplasty-group 1 or IHR onlay method with abdominoplasty-group 2. We evaluated postoperative results and long-term QL changes (DAS24, SF-36 scales).

RESULTS

We noted abnormal wound healing (2), pneumonia (3) and dysesthesia (3) in patients from group 1, and abnormal wound healing (2), seroma (2), pneumonia (2), and dysesthesia (4) in group 2. Quality of life was improved in the functional, esthetic and psychological aspects.

CONCLUSIONS

One stage incisional hernia repair by onlay as well as sublay method with abdominoplasty are safe surgical methods improving the functioning of patients after major weight loss following RYGB. Sublay hernia repair and abdominoplasty was connected with longer time of the: operation, drainage, analgesic agents use, time to mobilization and to full oral diet than the onlay method. Significant improvement of the quality of life was noted after every subsequent step of surgical treatment in both groups. Reduction of the risk of BMI re-growth after bariatric surgery is related to the need for constant, specialized care for these patients at every stage of follow-up after bariatric surgery.

Risk Factors for Undergoing Elective Abdominal Contouring Surgery Shortly After Hospitalization

BACKGROUND

Having posthospital syndrome (PHS) at the time of an elective surgery increases the risk of postoperative adverse outcomes. The purpose of this article was to identify incidence and risk factors for having PHS at the time of abdominal contouring surgeries.

METHODS

Insurance claims from the Truven MarketScan Databases were used to identify patients who underwent outpatient abdominoplasty, liposuction, or panniculectomy between April 2010 and August 2015. Patients were presumed to have PHS if they were hospitalized within 90 d before surgery. Incidence rates of having PHS were calculated for patient groups defined by demographic data and comorbidities. Statistical inference based on adjusted odds ratios was used to evaluate the association of potential risk factors with PHS. A nonparametric regression method was used to demonstrate nonlinear effects of patient covariates on the risk of PHS.

RESULTS

This study included 18,947 patients who underwent abdominal contouring; 77% were female, and the mean age was 48.7 y (SD = 14.7). Six percent (n = 1045) of patients had PHS at the time of surgery. A significantly stronger association with PHS (P < 0.001) was observed in patients with deep venous thrombosis (adjusted odds ratio = 3.56), Elixhauser score > 8 (3.28), and smokers (2.16). Age was found to have a piecewise linear effect on PHS, with odds increasing by 2.1% per year over the age of 45 y.

CONCLUSIONS

Older patients have an increased risk of undergoing abdominal contouring surgery in a deconditioned state. Screening at-risk populations for PHS would help identify patients who need rehabilitation before operative intervention.