Common Complications and Management After Massive Weight Loss Patient Safety in Plastic Surgery

Practice Patterns and Perspectives of the Off-Label Use of GLP-1 Agonists for Cosmetic Weight Loss

BACKGROUND

The off-label use of glucagon-like peptide 1 (GLP-1) agonists for cosmetic weight loss has captured the interest of the public. However, there is a paucity of published data on their utilization, implications, and management, particularly in the plastic surgery community.

OBJECTIVES

This study aims to explore the current practice patterns of aesthetic plastic surgeons regarding the off-label implementation of GLP-1 agonists.

METHODS

A 35-question survey was sent to the 2600 members of The Aesthetic Society in July 2023. The survey collected physician demographics, practice settings, patient population demographics, and the use and management of GLP-1 agonists in their practice. No identifying variables were collected; all responses were anonymous.

RESULTS

A total of 368 respondents were included. A quarter of respondents (25.3%) prescribed or utilized GLP-1 agonists in their practice. Nearly a third (29.9%) reported personal use of the medication, of which 71 (70.3%) indicated it was for cosmetic weight loss. Many aspects of the current treatment, counseling, and follow-up practices were similar among prescribing plastic surgeons. However, there were discrepancies in screening, nutrition counseling, and perioperative management. The majority believed that GLP-1 agonists were effective for weight loss (68.9%), profitable for business (57.8%), and would recommend its implementation to other plastic surgeons (68.5%).

CONCLUSIONS

As leaders in the aesthetic field, it behooves plastic surgeons to take charge of shaping public opinion surrounding the growing off-label use of GLP-1 agonists for cosmetic weight loss. Plastic surgeons' leadership is imperative in establishing safe and ethical guidelines and protocols for proper screening, management, and patient care.

LEVEL OF EVIDENCE: 4

Bioglass/ceria nanoparticle hybrids for the treatment of seroma: a comparative long-term study in rats

Background: Seroma formation is a common postoperative complication. Fibrin-based glues are typically employed in an attempt to seal the cavity. Recently, the first nanoparticle (NP)-based treatment approaches have emerged. Nanoparticle dispersions can be used as tissue glues, capitalizing on a phenomenon known as 'nanobridging'. In this process, macromolecules such as proteins physically adsorb onto the NP surface, leading to macroscopic adhesion. Although significant early seroma reduction has been shown, little is known about long-term efficacy of NPs. The aim of this study was to assess the long-term effects of NPs in reducing seroma formation, and to understand their underlying mechanism. Methods: Seroma was surgically induced bilaterally in 20 Lewis rats. On postoperative day (POD) 7, seromas were aspirated on both sides. In 10 rats, one side was treated with NPs, while the contralateral side received only NP carrier solution. In the other 10 rats, one side was treated with fibrin glue, while the other was left untreated. Seroma fluid, blood and tissue samples were obtained at defined time points. Biochemical, histopathological and immunohistochemical assessments were made. Results: NP-treated sides showed no macroscopically visible seroma formation after application on POD 7, in stark contrast to the fibrin-treated sides, where 60% of the rats had seromas on POD 14, and 50% on POD 21. At the endpoint (POD 42), sides treated with nanoparticles (NPs) exhibited significant macroscopic differences compared to other groups, including the absence of a cavity, and increased fibrous adhesions. Histologically, there were more macrophage groupings and collagen type 1 (COL1) deposits in the superficial capsule on NP-treated sides. Conclusion: NPs not only significantly reduced early manifestations of seroma and demonstrated an anti-inflammatory response, but they also led to increased adhesion formation over the long term, suggesting a decreased risk of seroma recurrence. These findings highlight both the adhesive properties of NPs and their potential for clinical therapy.

Circumferential Surgical Contouring of the Upper and Lower Body

Body contouring surgeons encounter a wide range of deformities affecting multiple areas of the body. Combining and staging procedures can assist in optimizing outcomes, but there is no one-size-fits-all approach to surgical sequencing and timing. A meticulous, individualized approach to preoperative planning can lead to reliable, aesthetically pleasing results that align with the patient's goals and preferences. In this article, we present our latest ideas on circumferential body contouring surgery and discuss the integration of lower body lift procedures with those of the abdomen, upper body, breasts, back, and arms to create a comprehensive 360° transformation.

Comorbid Conditions and Complications in Body Contouring Surgery: A Retrospective Review

Background

Body contouring procedures have significantly increased in popularity in the United States.

Objectives

The authors sought to understand, categorize, and classify patients' experiences with postoperative complications following common body contouring procedures.

Methods

PearlDiver (PearlDiver Technologies, Colorado Springs, CO), a database with over 90 million patients, was queried to identify patients who had undergone body contouring procedures between 2010 and 2021 using current procedural terminology (CPT) codes. The authors identified patients who underwent panniculectomy, abdominoplasty, brachioplasty, thighplasty, mastopexy, breast augmentation, augmentation mastopexy, breast reduction, and liposuction for analysis. They reviewed combined procedures and analyzed risk factors associated with the most common complications.

Results

There were 243,886 patients included in the study. The majority of patients were female, between 50 and 59 years old, and had their procedures performed in the southern United States. There were an average of 25,352 procedures per year. The majority of cases involved breast surgeries. The most common preoperative comorbid conditions diagnosed 1 year before surgery were hypertension, obesity, and diabetes. The most common postoperative complications within 90 days were wound dehiscence, hematoma, and urinary tract infection. A logistic regression evaluating the association of the preoperative comorbid conditions with postoperative complications found that patients with obesity, tobacco use, diabetes, and hypertension had an increased risk of developing wound dehiscence, hematoma, and surgical-site infection.

Conclusions

The data suggest that patients with obesity, tobacco use, diabetes, and hypertension undergoing body contouring surgery are at greater risk of developing wound dehiscence, hematomas, and surgical-site infections. Understanding this data is imperative for providers to adequately identify associated risk factors, stratify patients, and provide adequate perioperative counseling.

Level of Evidence 2

Management of Postoperative Seroma: Recommendations Based on a 12-Year Retrospective Study

Introduction: Seroma formation is a serious postoperative complication. Since the management algorithms available in the literature are scarce, we aimed to analyze our experience with postoperative seroma in order to identify indicators for revisional surgery and propose recommendations for management. Methods: This retrospective study included all patients with postoperative seroma treated in a tertiary university hospital from 2008 to 2020. Patients’ demographics, medical history, and seroma treatment details were recorded and analyzed. Results: Overall, 156 patients were included: 41% were initially treated through needle aspiration, with 61% eventually undergoing surgical treatment for postoperative seroma. Comorbidities, such as heart failure and coronary heart disease, were significantly associated with an increased need for revisional surgery (p < 0.05). Both a duration of >40 days of repeated needle aspirations and drain re-insertions were significantly correlated with an increased risk for revisional surgery (p < 0.05). Conclusion: Patients requiring seroma aspiration should be counseled on surgical treatment sooner rather than later, as prolonged aspiration time (over 40 days) greatly increases the risk of surgical revision. Moreover, the reinsertion of a drain should only be used as a temporizing measure, at most, and patients requiring a drain to control the size of the seroma should promptly be scheduled for a surgical revision.

Complications in post-bariatric body contouring surgery using a practical treatment regime to optimise the nutritional state

Background

Post-bariatric body contouring surgery (BCS) treats redundant skin after massive weight loss; however, the complication risk is relatively high (23-70%). Most complications are wound-related, which may be partly due to a poor nutritional status after bariatric surgery. The objective of this observational study was to optimise nutrition preoperatively and assess the prevalence of wound-related complications after BCS.

Methods

This prospective cohort study included 140 patients. Patients were treated according to the post-bariatric BCS guideline. Nutritional parameters were collected via pre- and peri-operative blood sampling; any deficiencies were treated. A protein-enriched diet was prescribed by a dietician 4 weeks preoperatively up until closure of all wounds. Complications were recorded using the Clavien-Dindo classification. Univariate and multivariate regression analyses were performed to identify variables associated with wound-related complications.

Results

The overall wound-related complication rate was 51%. Most complications were minor, with only 4.3% was considered major. No significant differences in patient characteristics were found between patients with and without complications. Variables indicating an optimised nutritional state were not significantly associated with a decreased risk of complications; the most influential factor was a sufficient post-operative protein intake (OR 0.27, 95% CI 0.07 – 1.02, p = 0.05).

Conclusion

The overall wound-related complication rate was in accordance with previous literature; however, major complications were few. This study showed a weak correlation between optimising nutritional state and better outcome after BCS, especially following a protein-enriched diet post-operatively. Therefore, we recommend continuing research on nutrition and wound-related complications, using homogeneous study populations and well-defined complications.

Vertical Medial Thigh Lift with the 'Anchor L Liposculpture' Technique in Massive Weight Loss Patients: Preliminary results

BACKGROUND

Among all post bariatric surgical procedures, vertical thigh lift has the highest complication rates. Many modifications have been described to achieve better aesthetic results and decrease complication rates. The study aimed to present ''Anchor L Liposculpture Technique'' and discuss the results in the light of current literature.

METHOD

Between 2016 and 2020, 33 patients were operated with the Anchor L Liposculpture technique. In this technique, liposuction is performed similarly with the other techniques, but the liposuction area is not extended to posterior or anterior compartments to prevent complications. The technique also used a deepithelized flap to anchor the superficial fascial system to the pubic arch periosteum. The patients' characteristics (age, sex, body mass index, smoking history, amount of weight loss, comorbidities) volume of liposuction and postoperative complications were recorded. Results were compared between uncomplicated (group A) and complicated patients (group B).

RESULT

Six (n=6, %18.2) out of 33 patients experienced complications (Group B). There were no major complication. The most common complications are wound dehiscence (n = 2) and lymphocele (n = 2). All complication cases managed conservatively. Age and amount of liposuction were found to be statistically associated with increased complications. Other comparisons between group A and B did not show any significant difference. Scar migration was not observed in any patient during follow-up.

CONCLUSION

Anchor L Liposculpture technique is an easy-to-apply and reliable technique aimed better surgical results and lower complication rates. Surgeons especially at beginning of the learning curve or who experienced high complication rates can utilize this technique.

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 www.springer.com/00266 .

Mechanical Thromboprophylaxis Alone in Body Contouring Surgery for Post Massive Weight Loss Patients: Is this Good Enough?

BACKGROUND

Although the use of pharmacological thromboprophylaxis effectively reduces Deep vein thrombosis (DVT) incidence after body contouring surgery, this might increase the risk of bleeding and hematoma formation. In this scenario, the use of mechanical prophylaxis alone could be an attractive alternative. We aimed to evaluate the incidence of DVT in patients with massive weight loss undergoing body contouring surgeries in whom mechanical prophylaxis alone was indicated.

METHODS

This retrospective cohort study included all patients who underwent body contouring surgery after massive weight loss between 09/01/16-12/31/19 and received solely mechanical prophylaxis of VTD. Data collected included smoking habit, body mass index, history of cancer, use of contraceptives, magnitude of weight loss, Caprini scale, American society of anesthesiology physical status (ASA-PS) classification, and type and length of procedures. An analysis of DVT events during the postoperative period up to 90 days was undertaken.

RESULTS

Sixty-four patients, in whom 82 BCS were performed, were included in this study. Most of them (89.1%) were female with a mean age of 47 ± 12 years. Mechanical prophylaxis methods used were elastic compression stockings, intermittent pneumatic compression boots, and early deambulation. In all cases, the average length of hospital stay was 26.3 ± 9.6 hours. Surgical times were less than 155,7 minutes in all procedures. Global incidence of DVT was 1.2% in a patient receiving mechanical prophylaxis alone. There were no bleeding complications or pulmonary embolism episodes.

CONCLUSIONS

In this series, DVT incidence in patients with mechanical prophylaxis alone was deemed acceptable if compared to the incidence reported in the literature. Individualization of the risk of thrombosis and bleeding in this group of patients is of paramount importance to reduce complications.

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 www.springer.com/00266 .

Complications of Body Contouring Surgery in Postbariatric Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Obesity is a major global health problem. With an increasing number of bariatric surgeries, the need for body-contouring procedures has grown. These procedures are associated with multiple complications because of various patient characteristics and risk factors.

OBJECTIVES

In this study, we performed a systematic literature review of all the complications of postbariatric body contouring surgeries, as well as a meta-analysis to estimate the effects of body mass index (BMI) and the weight of the tissue resected during body contouring on the development of complications.

METHODS

We conducted a literature search of the PubMed and Cochrane databases in September 2020, using the MeSH terms plastic surgery, weight loss, and complications. Studies were included if they involved more than 35 postbariatric patients and reported postoperative complication rates and types.

RESULTS

In total, 561 articles were initially identified, and 25 studies were included after the final review. The overall weighted rate of postbariatric body contouring surgical complications in all studies was 31.5%. The most frequent complication from all regions of body contouring was seroma (weighted rate 12.7-13.9%). Regarding risk factors, analysis indicated that a BMI < 30 kg/m² and low mean weight of resected tissue were associated with fewer complications.

CONCLUSION

Body contouring procedures are relatively safe. Although complications after contouring are common, most either resolve spontaneously or require minimal intervention. In body contouring after bariatric surgery, there is a 37% increased risk of developing complications if the BMI is ≥ 30 kg/[Formula: see text] before body contouring. A higher weight of resected tissue appears to be linked to a greater risk of 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 .

The Effect of Obesity, Bariatric Surgery, and Operative Time on Abdominal Body Contouring Outcomes

BACKGROUND

Abdominal body contouring procedures are associated with the highest rates of complications among all aesthetic procedures. Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications.

OBJECTIVES

The purpose of this single-institution study was to assess complication rates, and to evaluate BMI, operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery.

METHODS

A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential lower body lift, fleur-de-lis panniculectomy (FDL), and circumferential FDL between August 2014 and February 2020. Endpoints were the incidence of venous thromboembolism, bleeding events, seroma, infection, wound complications, and reoperations. Univariate statistical analysis and multivariate logistic regressions were performed. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery.

RESULTS

A total of 632 patients were included in the study. Univariate analysis revealed that longer procedure time was associated with infection (P = 0.0008), seroma (P = 0.002), necrosis/dehiscence (P = 0.01), and reoperation (P = 0.002). These associations persisted following multivariate analyses. There was a trend toward history of bariatric surgery being associated with minor reoperation (P = 0.054). No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population.

CONCLUSIONS

In abdominal body contouring surgery, surgery lasting longer than 6 hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation.

LEVEL OF EVIDENCE: 4

Outcome of Body-Contouring Procedures After Massive Weight Loss

BACKGROUND

With the increased popularity of bariatric surgery, the demand for body-contouring procedures is growing. Associated with these procedures are a number of complications due to different risk factors and patients' characteristics. The aim of this study was to assess the outcome of body-contouring procedures and correlate it to possible risk factors.

METHODS

The study included a collective of 112 patients who underwent 157 body-contouring procedures. Patients' characteristics, risk factors, and complications have been recorded. Three groups were formed based on the type of surgical procedure to perform correlations of BMI, weight of resected tissue, and length of hospital stay using Spearman's rank test. Correlations between patients' risk factors and complication occurrence were analyzed with Fisher's exact test.

RESULTS

The most common procedure patients underwent was the classic abdominoplasty (n = 53). A significant correlation was found between preoperative BMI and weight of resected tissue in abdominoplasties (rho = 0.69), Fleur-de-Lis abdominoplasties (rho = 0.64), and body lifts (rho = 0.60). There was a significant correlation between weight of resected tissue and length of hospital stay (rho = 0.53) and preoperative BMI and length of hospital stay (rho = 0.4) as well. There was no significant correlation between patients' comorbidities or smoking status and the postoperative complication rate. The mean weight of resected tissue was higher in patients with than without complications requiring surgical revision.

CONCLUSIONS

The relevance of risk factors commonly believed to have an influence on postoperative complications should be revised. The weight of resected tissue has an influence on complication.

Risk factors and complications after body-contouring surgery and the amount of stromal vascular fraction cells found in subcutaneous tissue

Body contouring surgery following massive weight loss is often prone to complications. Subcutaneous adipose tissue is a rich source of stromal vascular fraction (SVF) cells, and moreover it plays an important role in the pathophysiology of obesity, metabolic syndrome, and wound healing. In this retrospective, single-centred appraisal, complications are examined and correlated with individual SVF numbers in abdominal subcutaneous fat tissue. We analysed whether the weight loss method affected complications. Eighty seven massive weight loss patients undergoing body contouring surgery between 2010 and 2017 were included in the study. In total, 57 cases with at least one complication were recorded (65.5%). Maximum lifetime weight was 109.6 kg (range 48-184 kg). Half of the complications (50.8%) were minor complications without the need for surgical revision. The mean number of SVF found in the resected tissue was 714 997.63 cells/g fat tissue. We found no statistical difference in complication rates dependent on cell numbers. Smoking (P = .049) and a high BMI at the time point of surgery (P = .031) led to significantly more complications. Also, a high resection weight (P = .057) showed a tendency for impaired wound healing. However, there was no difference in complication rates following body contouring procedures attributable to the method of weight loss in this study.