Nutritional assessment of bariatric surgery patients presenting for plastic surgery: a prospective analysis

Preparing Patients for Body Contouring Surgery and Postoperative Surveillance for Deep Venous Thrombosis

This article highlights the importance of the preoperative evaluation and considerations necessary in preparing patients for body contouring surgery after massive weight loss (MWL). The importance of evaluating such factors as body mass index stabilization, medical comorbidities, nutritional optimization, social factors, deep venous thrombosis prophylaxis, and postoperative surveillance is critically important. Patients undergoing body contouring surgery after MWL are at increased risk of thromboembolic events, and prophylactic measures should be taken to minimize this risk. Overall, a thorough preoperative evaluation is essential to ensure patient safety, optimize surgical outcomes, and address the unique challenges presented by the MWL patient population.

Litigation Cases After Post-Bariatric Surgery: Lesson from the Past

BACKGROUND

Due to the high demand of post-bariatric surgeries, the number of litigation cases is rapidly growing. Even if surgical mistakes still represent one of the main causes of medico-legal issues, many disputes depend on what happens in the post-operative course. In this article we analyzed the litigation cases that occurred in our Plastic Surgery Department, the current literature about medico-legal disputes and the importance of the doctor-patient relationship.

PATIENTS AND METHODS

The medical records of 788 post-bariatric surgeries, the post-operative complications and the related litigation cases from January 2015 to December 2019 were collected, analyzed and compared.

RESULTS

We performed 380 abdominoplasties, 28 torsoplasties, 65 breast reductions, 99 mastopexies, 94 brachioplasties, 52 thighplasties, 65 liposuctions and 5 facelifts between 2015 and 2019. Eight patients complained of medical issues and claimed for litigation. Despite in all cases the judges highlighted the risk of consent misinterpretation, the payout was granted only in one case.

CONCLUSION

Post-bariatric patients often mistake their preoperative condition and consider body contouring procedures as an aesthetic surgery treatment. Patients should be therefore clearly informed about the complexity of body contouring procedures after massive weight loss, which should never be compared to aesthetic surgery. Surgeons should always promote the communication with their patients and build a strong and trustworthy relationship. This attitude will allow to deal more easily with complications and, in the worst situations, with medico-legal litigations.

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 .

Current Practices and Guidelines for Perioperative Blood Management in Post-Bariatric Body Contouring Surgery: A Comprehensive Review of Literature

With the increase in obesity prevalence, a noticeable increase in bariatric surgeries has been reported in national and international statistics. Therefore, body contouring surgeries have increased to help individuals achieve their desired body shape. Plastic surgeons need to consider potential hematologic complications that may occur in this specific group of patients before performing body contouring surgery. This review illustrates the perioperative medical, laboratory, and management strategies needed to minimize blood loss and blood transfusion requirements during body contouring. Using Google Scholar and PubMed, a comprehensive literature review was conducted to identify articles discussing post-bariatric body contouring perioperative blood management strategies, including the effects of bariatric surgery on hemostasis as well as basic hematology and coagulation. In preoperative blood management, blood investigations aid in the early detection of electrolytes, protein, and vitamin deficiencies and anemia, resulting in the early correction of nutritional deficiencies. In order to reduce postoperative complications, surgical and anesthesia techniques, as well as intraoperative pharmacological therapy, play an essential role. Postoperative blood transfusion and restrictive transfusion thresholds are tailored to the patient's needs and depend on various physiological indicators, such as heart rate, blood pressure, urine output, and laboratory findings, such as acidosis and hematocrit level. Generally, post-bariatric body contouring blood management measures are still lacking, and more research is required to develop standardized guidelines for optimizing patient safety and satisfaction.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 .

Complications Post Abdominoplasty After Surgical Versus Non-surgical Massive Weight Loss: a Comparative Study

PURPOSE

This study aims to investigate the rate of short- and long-term complications as well as the need for operative revisions after abdominoplasty for patients following surgical versus non-surgical weight loss methods.

METHODS

This is a retrospective chart review that enrolled consecutive patients undergoing abdominoplasty across a 5-year period, aged 18 years and above, opting for abdominoplasty after weight loss achieved through bariatric surgery or diet and exercise alone.

RESULTS

A total of 364 patients lost weight through bariatric surgery and 106 by diet and exercise alone. There were no significant differences in comorbidity status, but past body mass index (BMI) was higher for the surgical weight loss (SW) group (47.6 ± 10.2 and 40.4 ± 8.6, respectively; p value < 0.0001). Percent excess weight loss (EWL) was 68 ± 14.5 for the SW group and 55.7 ± 19.4 for the NSW group, p value < 0.0001. Pre- and postoperative blood hemoglobin levels were significantly lower in the SW group (p < 0.05). Neither short-term complications (thromboembolic events, wound complications, or infections) nor long-term complications (umbilical deformity, delayed wound healing, or infection) and operative revisions were significantly different across both groups (p > .05).

CONCLUSION

Bariatric surgery does not increase the risk of short- or long-term complications or the need for operative revision after abdominoplasty.

Nutritional Support for Bariatric Surgery Patients: The Skin beyond the Fat

Body contouring surgery after the massive weight loss due to bariatric surgery deals with different kinds of complications. The aim of this review is to analyze the role that some nutrients may play in tissue healing after surgery, thus helping plastic surgeons to improve the aesthetic and health outcomes in massive weight loss patients under a multidisciplinary approach. As a matter of fact, preoperative nutritional deficiencies have been shown for vitamins and minerals in a large percentage of post-bariatric patients. Preoperative deficiencies mainly concern iron, zinc, selenium, and vitamins (both fat-soluble and water-soluble), but also total protein. During the postoperative period, these problems may increase because of the patients' very low intake of vitamins and minerals after bariatric surgery (below 50% of the recommended dietary allowance) and the patients' low compliance with the suggested multivitamin supplementation (approximately 60%). In the postoperative period, more attention should be given to nutritional aspects in regard to the length of absorptive area and the percentage of weight loss.

Panniculectomy: Practical Pearls and Pitfalls

Panniculectomy is an increasingly common operation, given the current obesity epidemic and the increasing prevalence of bariatric surgery. At first glance, it could be considered a technically simple operation; however, this procedure can be fraught with complications, given the patient population and high demands placed on compromised abdominal tissue. Sufficient attention must be given to the nuances of patient optimization and surgical planning to maximize safe and ideal outcomes. We highlight our practical tips when performing standard or massive panniculectomy for preoperative optimization, intraoperative techniques, and postoperative management to reduce complication and maximize outcomes of this procedure from a surgeon's and a patient's perspective.

Two-year outcomes of sleeve gastrectomy versus gastric bypass: first report based on Tehran obesity treatment study (TOTS)

BACKGROUND

Bariatric surgery is an effective treatment for obesity and its associated comorbidities. This is the first comprehensive report of a prospective cohort study, comparing sleeve gastrectomy (SG) with gastric bypass (GB) regarding their effectiveness and safety.

METHODS

The prospectively collected data of patients, who presented to a specialized bariatric center and underwent a primary bariatric procedure, were compared in terms of weight loss, remission of obesity-associated comorbidities, complication rate, and quality of life improvement at 6-, 12-, and 24-month follow-ups.

RESULTS

Of 3287 patients (78.6% female) analyzed, 67% (n = 2202) and 33% (n = 1085) underwent SG and GB, respectively. Effective outcomes were reported in both groups regarding the body composition indices. Type 2 diabetes mellitus (T2DM) remission rate at the end of follow-up was 53.3% and 63.8% in the SG and GB groups, respectively. Following the propensity score-adjusted analysis, the T2DM remission rate was not significantly different between the groups. Conversely, the remission rate of hypertension in the 24-month follow-up (39.1% vs. 54.7%) and the remission rate of dyslipidemia in all follow-ups were lower in the SG group, compared to the GB group. Moreover, both procedures caused substantial improvements in various domains of quality of life. The surgery duration, early complication rate, and nutritional deficiencies were lower in the SG group, compared to the GB group.

CONCLUSION

Both surgical procedures were effective in the control of obesity and remission of its comorbidities. However, since SG was associated with a lower rate of complications, it seems that SG should be considered as a suitable procedure for obese patients, especially those with a healthier metabolic profile.

Surgical Site Infection Risk Factor Analysis in Postbariatric Patients Undergoing Body Contouring Surgery: A Nested Case-Control Study

BACKGROUND

Surgical site infections (SSIs) following body-contouring plastic surgery pose a significant burden on patients and caregivers, possibly leading to undesired surgical outcomes. Surgical site infection incidence following body-contouring plastic surgery ranges from 2% to 7%, but is estimated much higher among postbariatric massive weight loss (MWL) patients.

OBJECTIVE

The aim of this study was to evaluate SSI rate, risk and protective factors among postbariatric MWL patients following body-contouring plastic surgery.

METHODS

This was a nested case-control study of MWL patients who underwent body-contouring plastic surgery at the Department of Plastic Surgery at Assaf Harofeh Medical Center, between 2007 and 2014. Data were obtained from medical records. Surgical site infection was defined according to the Centers for Disease Control and Prevention criteria. Logistic regression was conducted to assess independent risk factors for SSIs.

RESULTS

From a cohort of 172 patients, 86 were included in the study. Surgical site infection rate was 20% (n = 17). Significant SSI risk factors included lifetime maximal weight and lifetime maximal body mass index (P = 0.039 and P = 0.002, respectively), body mass index loss prior to surgery (P = 0.032), estimated blood loss during surgery (P = 0.002), and gynecomastia repair procedure (P = 0.038). Independent SSI-associated factors included thigh lift procedure (odds ratio, 4.66; 95% confidence interval, 1.13-19.28) and preoperative antimicrobial prophylaxis (odds ratio, 0.04; 95% confidence interval, 0.03-0.61).

CONCLUSIONS

Although not required by current guidelines for body-contouring plastic surgery, preoperative antimicrobial prophylaxis in our study demonstrated a significant protective effect against SSIs. Further research may reveal its true contribution to SSI prevention in body-contouring plastic surgery.

Abdominoplasty After Massive Weight Loss

After massive weight loss (MWL), patients present with deformities that are more severe and often different than those observed in standard cosmetic abdominoplasty. The first step is careful consideration of the special factors involved in preoperative screening of patients with MWL presenting for body contouring surgery. Once these patient factors are optimized and surgery is considered, careful analysis of anatomic deformities should ensue. Technical variations of standard abdominoplasty are often required. With proper attention to safe screening, analysis of the anatomic deformities, and application of relevant techniques, plastic surgeons can have a positive impact on the lives of these patients.

Getting the Most Out of Augmentation-Mastopexy

LEARNING OBJECTIVES

After reviewing the article, the participant should be able to: 1. Understand the tenets of proper patient selection. 2. Be familiar with the assessment of patients for augmentation-mastopexy. 3. Be able to plan an operative approach and execute the critical steps. 4. Be able to recognize common complications and have a basic understanding of their management. 5. Be aware of emerging adjunctive techniques and technologies with respect to augmentation-mastopexy.

SUMMARY

Despite being a multivariable and complex procedure, augmentation-mastopexy remains a central and pivotal component of the treatment algorithm for ptotic and deflated breasts among plastic surgeons. Careful preoperative planning, combined with proper selection of approach and implant, can lead to success. Physicians need to understand that there is a high frequency of reoperation cited in the literature with regard to this procedure, and discussions before the initial operation can help alleviate common misunderstandings and challenges inherent in this operation.

Safety in Body Contouring to Avoid Complications

Body contouring after weight loss is becoming more prevalent. An appropriate systematic approach that starts from the first consultation needs to focus on residual comorbidities and weight of the patient. A thorough discussion about potential outcomes manages expectations. Preoperative optimization with smoking, herbal cessation, and nutritional assessment is mandatory. Planned staged approach minimizes lengthy procedures associated with increased postoperative morbidity. In the operating room, appropriate ambient temperature, positioning of the patient, and continuous discussion between surgeon and anesthesiologist prevent further complications. Careful transition to postoperative care with early ambulation and use of compressive garments add to an approach to minimize postoperative complications.

What Is the Impact of Comorbidities on the Risk for Postoperative Body-Contouring Surgery Complications in Postbariatric Patients?

BACKGROUND

There is an increasing number of patients presenting after massive weight loss for plastic surgery, and many of these patients have residual diseases that may compromise outcomes. This study aims to evaluate the impact of comorbidities on the development of postoperative complications in postbariatric patients undergoing plastic surgery procedures at the Federal District North Wing Regional Hospital, Brasília, Brazil.

METHODS

Descriptive, analytical, and prospective study was performed on patients who underwent plastic surgery following RYGB from January 2011 to December 2016. Measures included BMI (body mass index) before RYGB and before plastic surgery, medical complications and comorbidities.

RESULTS

One hundred thirty-nine patients (130 female, 9 male) with a mean age of 41 years underwent 233 separate operations. The average BMI at the time of plastic surgery was 27.44 kg/m². The average weight loss was 47.02 kg, and the mean pre-weight-loss BMI (max BMI) was 45.17 kg/m². The most important pre-plastic comorbidities were arterial hypertension (11.5%), degenerative arthropathy (5.4%), diabetes mellitus (5.0%), and metabolic syndrome (4.3%). Of the 139 patients operated upon, 76.97% underwent abdominoplasty followed by mammoplasty (42.46%). The overall rate of complications was 26.65%. Initially, on univariate regression analyses, comorbidities influenced the development of postoperative complications. However, after multiple logistic regression, the most important comorbidities failed to predict an increased risk of complications.

CONCLUSION

In this group of patients, with these anthropometric and clinical profiles, the most important comorbidities (diabetes, arterial hypertension, and metabolic syndrome) failed to influence the incidence of postoperative complications in postbariatric patients after plastic surgery.

Improving Abdominal Plastic Scars with a Dietary Supplement-A Comparative Study

Introduction:

Massive weight loss following bariatric surgery has a major functional and aesthetic impact on patients. Many patients are nonetheless reluctant to undergo plastic surgery in connection with their former obesity because they fear potentially large scars, even though such scars are not visible (ie, they are covered by undergarments).

Purpose:

The aim of this study was to evaluate the quality of wound healing in patients receiving Celergen supplementation following abdominoplasty, compared with a control group. The hypothesis was that supplementation would speed up wound healing and improve scar quality.

Materials and Methods:

We conducted a prospective, monocentric, controlled study of patients undergoing abdominoplasty. A group of patients received Celergen, a food supplement, for 3 months and were monitored for 1 year after their surgery.

Results:

Of 33 patients who underwent abdominoplasty, 25 received Celergen supplements. There was no significant difference between the 2 groups. The mean time to wound healing was significantly better in the group receiving supplementation compared with the control group [respectively, 24.6 ± 9.31 days and 34 ± 13.48 days (P = 0.03)]. The Patient and Observer Scar Assessment Scale (POSAS) observer score was significantly better at 1 year in the group receiving supplementation compared with the control group [12.68 ± 6.6 and 17.38 ± 5.24 (P = 0.01), respectively]. There was no significant difference in the total POSAS score at 1 year (P = 0.166).

Conclusion:

Celergen supplementation significantly improved the time to healing and the POSAS observer score at 1 year for patients undergoing abdominoplasty.

Autologous breast reconstruction in the postbariatric patient population

BACKGROUND

Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution.

METHODS

Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts.

RESULTS

Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00).

CONCLUSIONS

As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.

Predictive Value of Nutritional Markers for Wound Healing Complications in Bariatric Patients Undergoing Panniculectomy

BACKGROUND

Hypoproteinemia and nutritional deficiencies are common after bariatric surgery, and although massive weight loss (MWL) patients experience increased wound complication rates, the association has not been causatively determined.

OBJECTIVES

This study investigated preoperative nutritional parameters and wound complications in MWL patients (postbariatric and diet-controlled) undergoing panniculectomy at 2 academic institutions.

METHODS

One hundred sixty-one consecutive patients undergoing elective panniculectomy after bariatric surgery or diet-controlled weight loss were identified. Patient demographics and nutritional indices (serum protein, albumin, and micronutrient levels) were analyzed. Complications including wound separation, infection, and operative debridements were compared. Post hoc comparisons tested for correlation between complications and nutritional markers.

RESULTS

Postbariatric patients lost an average of 151 lb and presented at an average of 32 months after gastric bypass. Diet-controlled weight loss patients lost an average of 124 lb. Despite MWL, albumin levels were higher in the bariatric group (3.8 vs 3.4 g/dL, P < 0.05). Conversely, bariatric patients experienced increased wound complications (27% vs 14%; P < 0.05). Factors which were found to correlate to increased risk of wound dehiscence and infection were elevated body mass index at time of panniculectomy and amount of tissue removed. Multivariate analysis did not show serum albumin or percent weight loss to independently predict complications.

CONCLUSIONS

Bariatric patients presenting for elective operations are at risk for protein and micronutrient deficiency. Despite aggressive replacement and normalization of nutritional markers, bariatric patients experience increased wound complications when compared to nonbariatric patients and traditional measures of nutritional evaluation for surgery may be insufficient in bariatric patients.

Complications in body contouring stratified according to weight loss method

Background

Body contouring procedures following massive weight loss have become increasingly common and, unfortunately, continue to be associated with a high complication rate.

Objective

To evaluate how weight loss method affects complications following abdominally based body contouring procedures.

Methods

Patients undergoing abdominally based contouring procedures were retrospectively evaluated over an 11-year period and stratified into two groups based on method of weight loss: diet and exercise; or bariatric surgery. Complications, including seroma, wound dehiscence, skin necrosis, infection, hematoma and venous thromboembolism, were included if they required intervention. An adjusted logistic model was used to examine the effect of weight loss method on aggregate complication rates.

Results

A total of 307 patients were included: 77 (25%) lost weight through diet and exercise; and 230 (75%) through bariatric surgery. Results from the logistic model showed no difference in complication rates between weight loss methods (OR 1.01 [95% CI 0.51 to 2.02]). However, there was a strong correlation between body mass index at the time of surgery and complication rates (OR 1.05 [95% CI 1.02 to 1.08]; P<0.01).

Conclusions

The findings reveal no difference in complication rates following abdominal body contouring procedures attributable to method of weight loss. Rather, there was a proportional rise in complication rates in patients with a higher body mass index at the time of surgery. Surgeons and patients should be aware of this trend, and it should be part of any discussion of abdominal body contouring procedures and informing patients of their risk profile.

Complications in body contouring stratified according to weight loss method

BACKGROUND

Body contouring procedures following massive weight loss have become increasingly common and, unfortunately, continue to be associated with a high complication rate.

OBJECTIVE

To evaluate how weight loss method affects complications following abdominally based body contouring procedures.

METHODS

Patients undergoing abdominally based contouring procedures were retrospectively evaluated over an 11-year period and stratified into two groups based on method of weight loss: diet and exercise; or bariatric surgery. Complications, including seroma, wound dehiscence, skin necrosis, infection, hematoma and venous thromboembolism, were included if they required intervention. An adjusted logistic model was used to examine the effect of weight loss method on aggregate complication rates.

RESULTS

A total of 307 patients were included: 77 (25%) lost weight through diet and exercise; and 230 (75%) through bariatric surgery. Results from the logistic model showed no difference in complication rates between weight loss methods (OR 1.01 [95% CI 0.51 to 2.02]). However, there was a strong correlation between body mass index at the time of surgery and complication rates (OR 1.05 [95% CI 1.02 to 1.08]; P<0.01).

CONCLUSIONS

The findings reveal no difference in complication rates following abdominal body contouring procedures attributable to method of weight loss. Rather, there was a proportional rise in complication rates in patients with a higher body mass index at the time of surgery. Surgeons and patients should be aware of this trend, and it should be part of any discussion of abdominal body contouring procedures and informing patients of their risk profile.

The Impact of Protein Nutritional Supplementation for Massive Weight Loss Patients Undergoing Abdominoplasty

BACKGROUND

As more patients undergo bariatric surgery to assist with weight loss, the demand for post-bariatric body contouring surgery, to address both functional and aesthetic concerns, is increasing. However, high wound healing complication rates remain a significant problem for these patients. One theory is that chronic malnourishment and hypoproteinemia may contribute significantly to these wound healing complications.

OBJECTIVE

The purpose of this study was to determine the effect of pretreatment protein nutritional supplementation on wound healing in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. Our hypothesis was that protein supplementation would decrease wound healing complications.

METHODS

A retrospective review was performed of 23 post-bariatric surgery patients undergoing abdominoplasty who received pretreatment protein nutritional supplementation. This group was compared with a historical control group of 23 post-bariatric surgery patients who underwent abdominoplasty in the period immediately before the implementation of the protein supplementation protocol. Patient demographics and procedural characteristics were similar for the two groups.

RESULTS

Forty-six patients were identified who had undergone abdominoplasty, half of whom were prescribed the protein supplementation protocol. Overall wound healing complication rates were significantly lower in the protein-supplemented group (0.0% vs. 21.8%, p = 0.04). There was no significant difference between the protein supplementation and historical control groups in regards to total complication rate.

CONCLUSIONS

Pretreatment protein supplementation is a simple intervention that can significantly decrease wound healing complications in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. LEVEL OF EVIDENCE 4: Therapeutic.

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.

Preoperative evaluation of the body contouring patient: the cornerstone of patient safety

The obesity pandemic has resulted in increasing cases of bariatric surgery and subsequent issues related to excess skin and laxity for patients. This patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the issues of the body contouring candidate and provides tools that may assist in surgical planning.

Desire for body contouring surgery after bariatric surgery: do body mass index and weight loss matter?

BACKGROUND

There is disparity between the number of postbariatric surgery subjects who desire body contouring and those who receive it due to lack of resources or insurance criteria.

OBJECTIVES

The authors evaluate the desire for body contouring after bariatric surgery and its relationship with demographic patient characteristics.

METHODS

Three hundred sixty patients who had undergone bariatric surgery procedures >1 year previously completed a questionnaire designed by the surgical team to analyze each patient's desire for body contouring by area (face, upper arm, upper back, chin/neck, chest/breast, waist/abdomen, lower back, rear/buttock), scored from 0 to 3 (do not want, want somewhat, want, want a great deal). Data were compared with patient characteristics, postoperative body mass index (BMI), amount of weight loss, and BMI difference (ΔBMI).

RESULTS

Most patients desired body contouring surgery, with high or very high desire for waist/abdomen (62.2%), upper arm (37.6%), chest/breast (28.3%), and rear/buttock (35.6%) contouring. Many patients (36.4%) cited "very high" expectations for how body contouring might change their appearance. Patients >50 years old and >3 years postsurgery had a significantly lower desire. Patients with a ΔBMI >10 and with a weight loss >20 kg showed a significantly stronger overall desire for body contouring compared with other groups.

CONCLUSIONS

Most patients desire body contouring surgery after bariatric surgery, and our multivariate analysis showed a significant positive association between female sex, younger age, amount of weight loss, and ΔBMI with desire for body contouring.

Mineral malnutrition following bariatric surgery

Moderate/severe obesity is on the rise in the United States. Weight management includes bariatric surgery, which is effective and can alleviate morbidity and mortality from obesity-associated diseases. However, many individuals are dealing with nutritional complications. Risk factors include: 1) preoperative malnutrition (e.g., vitamin D, iron); 2) decreased food intake (due to reduced hunger and increased satiety, food intolerances, frequent vomiting); 3) inadequate nutrient supplementation (due to poor compliance with multivitamin/multimineral regimen, insufficient amounts of vitamins and/or minerals in supplements); 4) nutrient malabsorption; and 5) inadequate nutritional support (due to lack of follow-up, insufficient monitoring, difficulty in recognizing symptoms of deficiency). For some nutrients (e.g., protein, vitamin B-12, vitamin D), malnutrition issues are reasonably addressed through patient education, routine monitoring, and effective treatment strategies. However, there is little attention paid to other nutrients (e.g., zinc, copper), which if left untreated may have devastating consequences (e.g., hair loss, poor immunity, anemia, defects in neuro-muscular function). This review focuses on malnutrition in essential minerals, including calcium (and vitamin D), iron, zinc, and copper, which commonly occur following popular bariatric procedures. There will be emphasis on the complexities, including confounding factors, related to screening, recognition of symptoms, and, when available, current recommendations for treatment. There is an exceptionally high risk of malnutrition in adolescents and pregnant women and their fetuses, who may be vulnerable to problems in growth and development. More research is required to inform evidence-based recommendations for improving nutritional status following bariatric surgery and optimizing weight loss, metabolic, and nutritional outcomes.

Post-bariatric surgery body contouring in the NHS: a survey of UK bariatric surgeons

BACKGROUND

Following massive weight loss, patients are left with folds of redundant skin that may cause physical and psychological problems. These problems can be addressed through body contouring procedures such as abdominoplasty and the thigh lift. Despite an exponential rise in the number of bariatric surgery procedures performed in the United Kingdom, there are no national guidelines on the provision of body contouring procedures after massive weight loss. We conducted a survey of UK Bariatric Surgeons to determine the pre-operative counselling that patients receive on this issue, their opinions towards post-bariatric surgery body contouring and current referral patterns to Plastic Surgery. By exploring the relationship between Bariatric and Plastic Surgery, we aimed to identify how the comprehensive treatment of patients undergoing bariatric surgery could be improved.

METHOD

A questionnaire was sent to 86 surgeon members of the British Obesity and Metabolic Surgery Society. Questionnaires were analysed from the 61/86 respondents (71% response rate).

RESULTS

92% of the responding surgeons feel that patients face functional problems relating to skin redundancy after massive weight loss, and a high percentage of patients complain about this problem. However, only 66% of surgeons routinely counsel patients about these problems before they undergo bariatric surgery. 96% of respondents feel that body contouring for these patients should be funded on the NHS in selected cases. However, it is difficult for patients to access consultation with a Plastic Surgeon and there are no explicit guidelines on the criteria that patients must fulfil to undergo body contouring surgery on the NHS. At present, these criteria are locally determined and represent a postcode lottery.

CONCLUSION

The NICE guidelines on obesity recommend that patients undergoing bariatric surgery should have information on, or access to plastic surgery where appropriate, but this standard is not being achieved. National guidelines on post-bariatric body contouring surgery are needed to improve the comprehensive treatment of these patients. The clinical and cost effectiveness of bariatric surgery has been well established. Further studies focussing on the outcome of body contouring after massive weight loss could support this becoming and integral part of the bariatric surgery pathway.

Complications in postbariatric body contouring: strategies for assessment and prevention

Massive weight loss patients present specific challenges to the plastic surgeon. Review of these issues may be valuable for the surgeon who does not specialize in this area. Obtaining excellent results involves a comprehensive perioperative approach, beginning with proper patient selection and appropriate expectations. Operative considerations such as hypothermia prevention and thromboembolic prophylaxis can play a role in improving outcomes and reducing morbidity. Appropriately focused postoperative care completes the surgical plan, leading to satisfying results for both patient and surgeon.