Does the Degree of Ptosis Predict the Degree of Psychological Morbidity in Bariatric Patients Undergoing Reconstruction?:

Psychological well-being as a motive for and result of post-bariatric body contouring procedures

Objective

This study investigates whether psychological well-being in post-bariatric patients seeking body contouring procedures differs from those who do not seek body contouring procedures, those who have already undergone body contouring procedures, and those who are unsure about body contouring procedures.

Methods

An anonymous, nonrandomized, cross-sectional survey study was designed. Psychological well-being of four groups of post-bariatric-patients (undergone body contouring procedures, seeking body contouring procedures, not seeking body contouring procedures, unsure about body contouring procedures) were compared.

Results

A total of 345 patients were included in this study. No significant difference between patients seeking body contouring procedures and those not seeking body contouring procedures was found with regard to depressive symptoms, self-esteem, and body image. Patients who had already undergone body contouring procedures scored lower on depressive symptoms (p = 0.035) and reported feeling more attractive (p < 0.001) and less insecure (p = 0.030) than patients who had not yet undergone body contouring procedures but sought it. Satisfaction with the result of the body contouring procedures was associated with lower depression levels (p < 0.001), higher self-esteem (p < 0.001) and a more positive body-image (p < 0.001).

Conclusions

Depressive symptoms or low self-esteem are not motivational factors for post-bariatric patients to seek body contouring procedures. Body contouring procedures are associated with improvement in psychological well-being in post-bariatric patients. Patients' satisfaction with the result of the body contouring procedures is significantly associated with positive psychological well-being.

Desire for Body Contouring Surgery after Bariatric Surgery: A Nationwide Cross-sectional Study in Saudi Arabia

Background

The obesity pandemic in Saudi Arabia has led to a high demand for bariatric surgery (BS). Post-BS patients experience rapid and massive weight loss, with most patients experiencing redundant skin, leading to a desire for body contouring surgery (BCS).

Methods

A cross-sectional study was conducted from September 2022 to May 2023 among patients who underwent BS in Saudi Arabia, using an online self-administered questionnaire. The questionnaire comprised sociodemographic data, weight, and BS-related questions, and the post-BS appearance questionnaire assessed the desire for BCS, excess skin satisfaction, and overall appearance.

Results

A total of 410 of the patients electively enrolled. The mean perceived satisfaction of post-BS patients with the body's excess skin was rated as 4.28 ± 1.69 out of 7 points. The overall desire for BCS among the post-BS population was equal to a collective mean desire of 2.10 ± 0.92 out of 4 points. The desired body sites for BCS were focused on the abdomen/waist, followed by the lower back, then upper arms, buttocks, and thighs. Only 25.1% of the patients fulfilled their desires and recently underwent BCS.

Conclusions

The study highlights the importance of incorporating plastic and reconstructive surgery as an integral part of the multidisciplinary approach to morbidly obese patients after BS and the need for national guidelines on the referral pathway for post-BS BCS.

Post-Bariatric Plastic Surgery: Abdominoplasty, the State of the Art in Body Contouring

Due to the increased prevalence of obesity in the last decades, bariatric surgery has been on the rise in recent years. Bariatric surgery is a compelling option for weight loss in obese patients with severe obesity-related comorbidities or for whom lifestyle modifications have proven ineffective. Redundant skin following significant weight loss is a common occurrence affecting up to 96% of patients who undergo bariatric surgery, negatively impacting physical and psychosocial health and detracting from activities of daily living. Statistics of the American Society of Plastic Surgeons show that 46,577 body contouring procedures were performed after massive weight loss in the USA in a 2020 report. Abdominoplasty, a well-established cosmetic surgery procedure for improving body contour, is performed by removing excess skin and fat from the abdominal wall and thereby restoring musculofascial integrity and skin elasticity, resulting in a more ideal body shape and increasing quality of life. Although abdominoplasty is a safe procedure, it has been associated with a higher complication rate compared with other body-contouring procedures. Technologic advances over the past decade have been developed as non-invasive alternatives or adjunctive tools to surgery to enhance cosmetic results and minimize complications. New energy-based technologies may supplant invasive surgery for mild to moderate skin laxity and/or diminish the extent of surgery and resulting scars. Plastic surgeons play a significant role in improving the quality of life of patients who suffer from obesity and underwent bariatric surgery. We are deeply convinced, however, that the advancement of knowledge and research in this field will determine the introduction of new technologies and custom-made techniques. This advancement will reduce the complication rate with a rapid reintegration of the patient into the world of work and resumption of daily activities.

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.

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 .

The complexity of body image following bariatric surgery: a systematic review of the literature

Poor body image is common among individuals seeking bariatric surgery and is associated with adverse psychosocial sequelae. Following massive weight loss secondary to bariatric surgery, many individuals experience excess skin and associated concerns, leading to subsequent body contouring procedures. Little is known, however, about body image changes and associated features from pre-to post-bariatric surgery and subsequent body contouring. The objective of the present study was to conduct a comprehensive literature review of body image following bariatric surgery to help inform future clinical research and care. The articles for the current review were identified by searching PubMed and SCOPUS and references from relevant articles. A total of 60 articles examining body image post-bariatric surgery were identified, and 45 did not include body contouring surgery. Overall, there was great variation in standards of reporting sample characteristics and body image terms. When examining broad levels of body image dissatisfaction, the literature suggests general improvements in certain aspects of body image following bariatric surgery; however, few studies have systematically examined various body image domains from pre-to post-bariatric surgery and subsequent body contouring surgery. In conclusion, there is a paucity of research that examines the multidimensional elements of body image following bariatric surgery.

Body Contouring After Bariatric Surgery

Individuals who undergo bariatric surgery generally experience rapid and dramatic weight loss. While the weight loss typically confers significant health benefits, an undesirable consequence is often excessive quantities of hanging, surplus skin. Some patients undergo body-contouring surgery (BCS) in order to improve health, mobility, appearance and psychological adjustment. While the majority of post-bariatric patients desire BCS in one or more body regions, a small percentage of patients receive such surgeries. Lack of knowledge about procedures, cost and (in the USA and several other countries) difficulty obtaining insurance reimbursement likely prevents many patients from undergoing BCS. Those who do undergo BCS appear to be at heightened risk for wound-healing complications. Despite these complications, the majority of patients report satisfactory BCS outcomes. The extant literature in this area provides a great deal of information about these issues; nevertheless, additional research is needed to further inform clinical management and improve patient outcomes.