Evaluation of the Weight Loss Patient Presenting for Plastic Surgery Consultation:

The Impact of Metabolic Syndrome on Postoperative Outcomes in Abdominal Body Contouring: A Propensity Score-Matched Nationwide Analysis

BACKGROUND

Metabolic syndrome (MetS) represents cardiometabolic dysregulation, defined by hypertension, obesity, diabetes, and dyslipidemia. There remains a significant gap in our understanding of whether MetS impacts outcomes of abdominal body contouring procedures. We aimed to assess the influence of MetS on postoperative outcomes of abdominal body contouring by concurrent abdominoplasty and panniculectomy.

METHODS

The ACS-NSQIP database was utilized to identify patients who underwent concurrent abdominoplasty and panniculectomy procedures from 2012 to 2022. Through propensity score matching, distinct cohorts were established based on the presence of MetS, characterized by patients receiving medical interventions for diabetes mellitus and hypertension, with a body mass index exceeding 30 kg/m2. Univariate and multivariate analyses were conducted to evaluate differences between groups.

RESULTS

A total of 14,642 patients underwent abdominal body contouring from 2012 to 2022. Following propensity score matching, 730 patients were included in the analysis, with 365 in each group (MetS vs. non-MetS). Bivariate analysis revealed a longer hospital length of stay (2.3 vs. 1.6 days; p = 0.007) in the MetS cohort compared to the non-MetS cohort. Patients diagnosed with MetS had an average length of stay of 0.6 days longer than non-MetS patients (95% CI [0.17, 1.01]; p = 0.007). No noteworthy disparities were observed in the rates of 30-day wound complications, mild systemic, and severe systemic complications, and readmission rates between the groups.

CONCLUSIONS

Our findings suggest that abdominal body contouring remains a secure option for patients with MetS. Nonetheless, the longer hospital length stays observed in patients with MetS may translate to increased overall costs to the healthcare system. Continued research is warranted to comprehensively assess the economic implications of MetS in the context of abdominal body contouring.

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 .

Clinical Practice Patterns in Abdominoplasty: 16-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery

BACKGROUND

The authors evaluated trends in practice patterns for abdominoplasty based on a 16-year review of tracer data collected by the American Board of Plastic Surgery as part of the continuous certification process.

METHODS

To facilitate comparison of an equal number of patients over time, tracer data from 2005 to 2021 were split into an early cohort (EC) (from 2005 to 2014) and a recent cohort (RC) (from 2015 to 2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, surgical techniques, and complication rates.

RESULTS

Data from 8990 abdominoplasties (EC, n = 4740; RC, n = 4250) were analyzed. RC abdominoplasties report a lower rate of complications (RC, 19%; EC, 22%; P < 0.001) and a lower rate of revision surgery (RC 8%; EC, 10%; P < 0.001). This has occurred despite the increased use of abdominal flap liposuction (RC, 25%; EC, 18%; P < 0.001). There has been a decline in the use of wide undermining (81% versus 75%; P < 0.001), vertical plication of the abdomen (89% versus 86%; P < 0.001), and surgical drains (93% versus 89%; P < 0.001). Abdominoplasty surgery is increasingly performed in an outpatient setting, with increased use of chemoprophylaxis for thrombosis prevention.

CONCLUSIONS

Analysis of these American Board of Plastic Surgery tracer data highlights important trends in clinical practice over the past 16 years. Abdominoplasty continues to be a safe and effective procedure with similar complication and revision rates over the 16-year period.

Patient Evaluation and Surgical Staging

The present article discusses the evaluation and surgical planning of body contouring procedures for weight loss patients. These patients require thorough preoperative evaluation and patient education. Distinction should be made between massive weight loss and moderate medication-assisted weight loss (MMA) as these patient populations are managed differently and there are unique preoperative considerations with the MMA population. Given that weight loss patients often have multiple concerns, combination procedures are often utilized and must be planned with the patient's goals and safety in mind.

Postbariatric Abdominoplasty: A Comparative Study on Scarpa Fascia Preservation Versus Classical Technique

BACKGROUND

Abdominoplasties performed with Scarpa Fascia preservation, improve recovery and reduce complications, particularly seroma. Bariatric patients who experience massive weight loss frequently seek body contouring procedures and represent a high-risk group. This study aimed to evaluate the effects of abdominoplasty with Scarpa Fascia preservation versus the classical technique in a bariatric population.

METHODS

A retrospective observational cohort study was performed between March 2015 and March 2021 in 65 postbariatric patients who underwent a classic full abdominoplasty (group A, N = 25) or a similar procedure except for the preservation of Scarpa fascia (group B, N = 40). Total and daily drain output, time until drain removal, long drainers (≥ 6 days), length of hospital stay, emergency department visit, readmission to the hospital, reoperation, local and systemic complications were the outcomes evaluated.

RESULTS

Group B had a 3-day reduction in time until drain removal (p < 0.001), a 62.6% reduction of total drain output (p < 0.001) and a 3-day reduction in the length of the hospital stay (p < 0.001). Long drainers (≥ 6 days) were highly reduced (from 56.0% in group A to 7.5% in group B) (p < 0.001). There was a lower incidence of liquid collections in group B, with a 66.7% reduction in seroma incidence.

CONCLUSIONS

Abdominoplasty with Scarpa Fascia preservation improves recovery by reducing drain output, allowing earlier drain removal and reducing long periods with suction drains. It also reduces hospital stay and seroma incidence. This technique modifies the high-risk postbariatric patient in such a major way that he behaves like a nonbariatric.

LEVEL OF EVIDENCE II

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 .

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.

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.

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

Safety of Rivaroxaban for Postoperative Venous Thromboembolism Prophylaxis Following Abdominal Body Contouring Surgery: 600 Patients

BACKGROUND

Reducing the incidence of venous thromboembolism (VTE) following abdominal body contouring surgery remains a top priority for patient safety. There is a lack of consensus regarding the optimal chemoprophylactic agent for postoperative VTE prophylaxis, and the role of oral anticoagulants warrants further investigation.

OBJECTIVES

The aim of this multisurgeon, single-institution study was to determine the safety and efficacy of a 7-day postoperative rivaroxaban regimen for VTE prophylaxis in abdominal body contouring surgery.

METHODS

A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential body lift, fleur-de-lis panniculectomy, or circumferential fleur-de-lis panniculectomy at our surgical center from August 2014 to November 2019. A 7-day postoperative course of once-daily 10 mg rivaroxaban, starting on postoperative day 1, was administered to every patient unless there was a contraindication. The 2 primary endpoints were the incidence of VTE and bleeding events.

RESULTS

A total of 600 patients were included in the study. There were no deaths. There were 4 (0.7%) incidents of VTE events: 2 (0.3%) patients suffered pulmonary embolus and 2 (0.3%) patients suffered a lower-extremity deep venous thrombosis. A total of 13 (2.2%) patients suffered complications related to bleeding. Of these, operative intervention for control and evacuation was required in 7 (1.2%) patients.

CONCLUSIONS

A 7-day postoperative course of once-daily rivaroxaban for VTE risk reduction in abdominal body contouring surgery is associated with a low incidence of VTE events and a low risk of bleeding complications.

LEVEL OF EVIDENCE: 4

Abdominoplasty in the Massive Weight Loss Patient: Are Aesthetic Goals and Safety Mutually Exclusive?

Background

The goals of abdominoplasty in massive weight loss (MWL) patients are often functional, with a greater emphasis on safety than on aesthetic rejuvenation. As important as functional improvements and safety are, however, there may be room for increasing the aesthetic potential of abdominoplasties in these patients.

Objectives

To determine the safety of the pursuit of aesthetic goals for abdominoplasty in MWL patients.

Methods

This is a retrospective study examining 910 consecutive female patients consisting of 3 groups: postpartum (n = 718), dietary MWL (n = 65), and bariatric MWL (n = 127). All patients were approached with a well-defined set of aesthetic goals which were pursued as needed and as feasible.

Results

The utilization of aesthetic abdominoplasty components was similar in all groups, supporting the assertion that the groups were subjected to a similar aesthetic emphasis. Logistic regression showed that a history of bariatric MWL was an independent risk factor for multiple complications (odds ratio 2.738, P = 0.014) and that elevated body mass index (BMI), smoking, diabetes, and age were likewise independent risk factors for complications. Propensity score-matched case-control pairs showed that bariatric MWL patients were more likely than dietary MWL patients to experience multiple complications (9.52% vs 0%, P = 0.031).

Conclusions

Bariatric MWL patients but not dietary weight loss patients seem to have a higher risk than postpartum patients. Other comorbidities (elevated BMI, smoking, diabetes, and age) seem to be more important predictors of complications than MWL status. Select MWL patients can likely be approached with an emphasis on aesthetic goals, without increasing risks as compared with the postpartum population.

Level of Evidence: 2

Standards and Trends in Lipoabdominoplasty

BACKGROUND

Lipoabdominoplasty has evolved over the last 6 decades through contributions from numerous luminaries in plastic and reconstructive surgery.

METHODS

The authors review historical perspective and provide a contemporary examination of trends in lipoabdominoplasty.

RESULTS

In 1967, Pitanguy popularized abdominoplasty (without liposuction) as a technique for augmenting ventral hernias repairs and subsequently for aesthetic improvement of the abdomen. After the introduction of suction assisted lipectomy by Illouz in 1983, abdominoplasty became a central tool in a diverse armamentarium of anterior and lateral abdominal wall contouring procedures. Liposuction was initially utilized with mini-abdominoplasty in order to improve contour. Subsequently, Matarasso advanced the safe combination of liposuction with full abdominoplasty. Additionally, he systematized the variety of cutaneous undermining, excision, and liposuction procedures utilized in abdominal contouring as indicated by the degree of skin laxity and musculofascial diastasis. Lockwood advocated high lateral tension closure of the superficial fascial system of the abdomen to improve the contour of the hips and flanks. Saldanha advanced selective undermining and anterior abdominal wall perforator preservation to minimize wound healing and seroma complications associated with lipoabdominoplasty procedures.

CONCLUSION

In abdominal contour surgery, surgeons can rely on classic techniques and algorithms that have withstood the test of time while modifying their approaches with advances backed by compelling and rigorously obtained evidence.

Postoperative Venous Thromboembolism Prophylaxis Utilizing Enoxaparin Does Not Increase Bleeding Complications After Abdominal Body Contouring Surgery

BACKGROUND

Venous thromboembolism (VTE) chemoprophylaxis warrants an individualized, risk-stratified approach, and constitutes a relatively controversial topic in plastic surgery.

OBJECTIVES

The aim of this study was to determine the safety of a 7-day postoperative enoxaparin regimen for VTE prophylaxis compared with a single preoperative dose of heparin in abdominal body contouring surgery.

METHODS

This single-institution pre-post study investigated the safety of a 7-day enoxaparin postoperative regimen in abdominal body contouring procedures performed by a single surgeon from 2007 to 2018. Four procedures were included: traditional panniculectomy, abdominoplasty, fleur-de-lis panniculectomy, and body contouring liposuction. Group I patients received a single dose of 5000 U subcutaneous heparin in the preoperative period, and no postoperative chemical prophylaxis was administered. Group II patients received 40 mg subcutaneous enoxaparin in the immediate preoperative period, then once daily for 7 days postoperatively.

RESULTS

A total of 195 patients were included in the study, 66 in Group I and 129 in Group II. The groups demonstrated statistically similar VTE risk profiles, based on the 2005 Caprini risk-assessment model. There were no statistically significant differences in the 2 primary outcomes: postoperative bleeding and VTE events. Group I patients had higher reoperation rates (22.7% vs 10.1%, P = 0.029), which was secondary to higher rates of revision procedures.

CONCLUSIONS

A 7-day postoperative course of once-daily enoxaparin for VTE risk reduction in abdominal body contouring surgery does not significantly increase the risk of bleeding. Implementation of this regimen for postdischarge chemoprophylaxis, when indicated following individualized risk stratification, is appropriate.

LEVEL OF EVIDENCE: 4

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.

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.

Evidence-Based Abdominoplasty Review With Body Contouring Algorithm

Abdominal contour deformities are an aesthetic challenge to the plastic surgeon. Patients present with diverse clinical histories, multiple comorbidities, and unique aesthetic demands. Weight loss, previous pregnancy, and aging are 3 principal indications for abdominoplasty. Bariatric surgery has increased demand for body contouring procedures. This heterogeneous patient cohort means a "one-size-fits-all" abdominoplasty is not appropriate. Precise evaluation, evidence-based decision-making, and artistic acumen are required while balancing patient goals with safe, realistic, and long-lasting aesthetic outcomes. This article reviews surgical options for abdominal body contouring, providing an evidence-based treatment algorithm for selecting the appropriate procedure for each patient to maximize clinical and patient reported outcomes.

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.

Complications after lower body contouring surgery due to massive weight loss unaffected by weight loss method

Body contouring surgery following massive weight loss positively affects a patient's quality of life. However, the procedure is prone to complications. Herein, we stratified complications timewise. Furthermore, we examined whether the weight loss method - bariatric surgery or lifestyle changes - affected the frequency or severity of complications. In this single-centre retrospective analysis, we included 158 patients with massive weight loss undergoing body contouring surgery between 2009 and 2015. We recorded 96 complications in 80 patients, with an overall rate of 51%. Most complications (80.2%) were minor (Clavien-Dindo grades 1 and 2) and superficial wound infections. Immediate complications (0-24 hours post-operation) affected 8.3% of patients, with early complications (1-7 post-operative days) affecting 16.7% of them and late complications (8-30 post-operative days) affecting 58.3% of them. We found no statistical difference in complication rates when comparing bariatric and non-bariatric patients. Older age (p = 0.042) at operation is associated with an increased risk for immediate haematoma or bleeding requiring surgery. Among early complications, a high maximum weight (p = 0.035) and a high preoperative weight (p = 0.0053) significantly correlated with a haematoma or bleeding requiring surgery. For late complications, seroma correlated with older age (p = 0.0061). Complications are primarily minor and non-life threatening after body contouring surgery because of frequent massive weight loss. Here, no particular subgroup of massive weight loss patients appeared more prone to complications. Thus, for each patient, the risks associated with body contouring surgery following massive weight loss should be considered individually.

Abdominal Contouring and Combining Procedures

The abdomen is the most common area of concern among patients with massive weight loss (MWL). Abdominal contouring techniques in the MWL population include panniculectomy, standard abdominoplasty, fleur-de-lis abdominoplasty, reverse abdominoplasty and various combinations of these techniques as part of circumferential procedures such as, circumferential abdominoplasty, and lower body lift. The authors believe that the optimal surgical approach to the abdomen is an integration of the patient aesthetic preferences and the surgeon assessment and experience. The authors recommend to limit total body reconstruction of MWL patients to 2 stages, and include the abdominal area in the first stage.

Patient Evaluation and Surgical Staging

Comprehensive evaluation of the massive-weight-loss patient is a key factor to minimize complications while optimizing surgical outcomes. Special attention is given to medical and weight loss history, nutritional status, and physical examination. Massive-weight-loss patients often present with multiple areas of concern and therefore benefit from staged procedures. Staging requires knowledge on how the tissues are affected by each procedure and an understanding of the patient's priorities and goals.

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.

Venous thromboembolism prophylaxis in the massive weight loss patient: relative risk of bleeding

BACKGROUND

Measures that can reduce the incidence of venous thromboembolism (VTE) are of great clinical importance. In addition to the use of sequential compression devices (SCDs), chemoprophylaxis with low-molecular-weight heparin (LMWH) has been recommended by the American College of Chest Physicians for major general surgery procedures. There remains inconclusive evidence to support guidelines for the plastic surgery population, and some surgeons hesitate to use anticoagulation due to concerns about bleeding in broad planes of dissection. The purpose of this study was to evaluate the risk of postoperative complications secondary to chemical thromboprophylaxis in massive weight loss patients.

METHODS

Five hundred forty-six surgical cases were enrolled in an institutional review board-approved prospective clinical database in the 2 years before and after routine LMWH use was initiated. Inclusion required weight loss of greater than 50 lb. Group 1 had SCDs only (n = 334), whereas group 2 had SCDs and LMWH 6 hours postoperatively (n = 212). Risk of VTE was calculated and complications of LMWH administration were analyzed.

RESULTS

The overall risk of deep venous thrombosis and pulmonary embolism was 0.18%. There was no statistical difference between the groups (P > 0.05). Overall risk of hematoma was 5.4%, in concordance with the literature. There was no difference in hematoma risk between the groups (4.6% before and 6.6% after LMWH; P = 0.3). The transfusion rate was 8.5% before use of LMWH (group 1) and 7.6% after (group 2; P = 0.7).

CONCLUSIONS

Strategies to reduce VTE rates remain important in all areas of plastic surgery. We have demonstrated no increased risk of transfusion or hematoma and a low overall incidence of VTE after implementing a chemoprophylaxis regimen. Postoperative LMWH can provide an excellent balance between VTE prophylaxis and the risk of bleeding complications.

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.

Plastic surgery after bariatric surgery

BACKGROUND

Massive weight loss after bariatric surgery often results in excess skin, which can lead to stigma due to appearance and pronounced physical and psychological impairments. This review considers the evidence base for post-bariatric plastic surgery and the treatment options that are available.

METHOD

The article is based on a literature search in PubMed with the keywords «bariatric surgery» AND «plastic surgery», in addition to the authors' experience with a large number of patients.

RESULTS

Body contouring surgery after massive weight loss is offered primarily for the treatment of troublesome skin conditions. The surgery can help to improve quality of life and functional status. However, there is little scientific evidence regarding indications for surgery, choice of surgical techniques and risk of complications, and the surgeon's own opinions and clinical experience often play a major role. Many plastic surgeons limit body contouring surgery to those with BMI < 28 kg/m². However, most patients who have undergone bariatric surgery have BMI ≥ 30 kg/m², and requests for body contouring surgery for these individuals are often denied, except when there are compelling medical grounds.

INTERPRETATION

Plastic surgery can lead to improved functioning and increased quality of life. The evidence base with respect to indications, treatment methods and outcomes should be strengthened through well-planned prospective studies and a patient registry. There is a particular need for documentation of treatment outcomes in the large group of patients with BMI ≥ 30 kg/m².

The effect of massive weight loss status, amount of weight loss, and method of weight loss on body contouring outcomes

BACKGROUND

The impact of massive weight loss (MWL) on body contouring procedures and outcomes has not been firmly established in the literature.

OBJECTIVE

The authors investigate the correlations between MWL status, the method of achieving MWL, and the amount of weight lost with wound-healing complications after body contouring procedures.

METHODS

The charts of 450 patients (124 of whom had undergone MWL) who underwent body contouring procedures including abdominoplasty, brachioplasty, thighplasty, breast mastopexy/reduction, lower bodylift, bodylift, buttock lift, and liposuction were reviewed. MWL patients were classified as having achieved weight loss through diet and exercise, gastric banding or sleeving, or gastric bypass. Postoperative complication data were collected, including cases of infection, delayed wound healing, seroma, hematoma, dehiscence, and overall wound problems. Odds ratios (OR) were estimated using 4 multivariate logistic regression models.

RESULTS

MWL status was a significant predictor of wound problems (OR, 2.69; P < .001). Patients with 50 to 100 lbs of weight loss did not have a significantly increased risk of wound problems (OR, 1.93; P = .085), while patients with over 100 lbs of weight loss did (OR, 3.98; P < .001). Gastric bypass (OR, 3.01; P = <.001) had a higher risk correlation than did diet and exercise (OR, 2.72, P = .023) or restrictive bariatric surgery (OR, 2.31; P = .038) as a weight loss method. Patients who lost over 100 lbs demonstrated increased risk of complications if they had gastric bypass or restrictive procedures.

CONCLUSIONS

MWL was a significant risk factor for wound complications in the body contouring population. Method and amount of weight loss were also significant factors in predicting complications.

The life after weight loss program: a paradigm for plastic surgery care after massive weight loss

Obesity has become a nationwide problem. In every state, at least 1 in 5 individuals is obese. Because of the obesity epidemic and the comorbidities associated with obesity, many people turn to bariatric surgery as a treatment option. The most popular bariatric procedures are Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding. With the success of these procedures, patients experience massive weight loss in a short period of time. Their weight loss can be from 50 lb to more than 100 lb. Because of this massive weight loss, patients are left with loose hanging skin. Body contouring in plastic surgery has increased in demand, following the popularity in bariatric procedures. In 2002, the Life After Weight Loss clinical program was established at the University of Pittsburgh, by Dr. J. Peter Rubin, Chair of the Department of Plastic Surgery, UPMC, and Director of the Life After Weight Loss Program.