Plastic Surgery Improves Long-Term Weight Control after Bariatric Surgery:

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE V

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

Satisfaction and Quality of Life in Patients Who Underwent Post Massive Weight Loss Body Contouring Procedures: A Tertiary Center Experience in Bahrain

Background

Incidence of body contouring surgeries (BCS) rose significantly to overcome problems resulted from post-Bariatric Surgery (BS). We aimed to evaluate satisfaction level and quality of life (QOL) in patients' post-BCS.

Methods

In this retrospective prospective study, patients who underwent BCS in Plastic Surgery Department, Salmaniya Medical Complex, Bahrain, in 2017-2018, were enrolled. Demographic and anthropometric data were collected. BS-group's QOL and satisfaction level were assessed using a questionnaire.

Results

Of 929 plastic surgery admissions, 316 (34%) were for BCS (249 patients). Fifty-eight (28%) patients underwent 82 BS were recruited, mostly females (n=42, 72.4%). The mean age was 37.4±9.6 years. Excess abdominal skin was the most area of concern (n=50, 86.2%). Median pre-BCS body mass index was 26.9 (interquartile range: 25.6-29.8) kg/m2. Most patients were overweight (n=26, 44.8%). Abdominoplasty was the commonest BCS (n=172, 50.6%). This was also the case in 82 BCS in post-BS group (n=38, 46.3%). In post-BS group, post-operative complications were noted in 25/82 (30.5%) patients with wound problems being the most frequent (n=14, 17.1%). Most patients rated their experience as better in all questionnaire domains and most (n=45, 54.9%) rated their satisfaction level as excellent. Older age gave better overall satisfaction (P<0.001) while employed patients had better overall QOL (P=0.012) and self-confidence (P=0.048). Females had better satisfaction with body appearance (P<0.001) while those underwent abdominoplasty or breast surgeries had lower physical activity (P=0.042).

Conclusion

This study showed improvement in patient's QOL post-BCS with excellent overall satisfaction, findings that could be affected by age, sex, and occupation.

Analyzing the Impact of Social and Psychiatric Factors in Patients Who Undergo Body Contouring Procedures

BACKGROUND

As the prevalence of obesity increases, the number of patients seeking body contouring procedures after bariatric surgery for massive weight loss is increasing. Although the positive impact of bariatric surgery on physical and emotional health is well-described, few studies have reported on the psychosocial well-being of patients undergoing body contouring procedures. Psychosocial well-being can impact patient satisfaction and maintenance of weight loss, and is an important area to study.

OBJECTIVE

The aim of this study was to characterize social and psychiatric factors of patients undergoing body contouring surgery, and to evaluate their impact on maintenance of weight loss.

METHODS

A retrospective review was performed of patients who presented to a single institution for body contouring procedures between 2002 and 2018. Demographic details, medical history, psychosocial support, and operative details were collected. Univariate analysis and multinomial logistic regressions were performed with R statistical software (version 1.3.1093).

RESULTS

A total of 1187 patients underwent at least 1 body contouring procedure during the study time frame. Mean BMI at presentation was 31.21 ± 10.49 kg/m2. Patients diagnosed with obesity at age 18 or older had significantly greater odds of suffering from generalized anxiety disorder (odds ratio [OR] 1.08 [95% CI, 1.02-1.15], P = .008). Patients with spousal support had 1.93 times higher odds of having maintained postbariatric weight loss at their 6-month follow-up (OR 1.93 [95% CI, 1.84-2.01], P = .028).

CONCLUSIONS

Social support and age of obesity diagnosis impact psychological well-being and maintenance of weight loss following body contouring procedures.

LEVEL OF EVIDENCE: 3

Abdominal Hypertension after Abdominal Plication in Postbariatric Patients: The Consequence in the Postoperative Recovery

Background  Abdominoplasty with abdominal plication increases intra-abdominal pressure (IAP) and has been previously associated with limited diaphragmatic excursion and respiratory dysfunctions. Many factors found in abdominoplasties and among postbariatric patients predispose them to a higher occurrence. This study aims to evaluate the impact of abdominal plication among postbariatric patients, assess whether the plication increases their IAP, and analyze how these IAP correlate to their postoperative outcome. Methods  This prospective study was performed on all patients who underwent circumferential Fleur-De-Lis abdominoplasty. For this intended study, the IAP was measured by an intravesical minimally invasive approach in three stages: after the initiation of general anesthesia, after a 10-cm abdominal wall plication and skin closure, and 24 hours after the procedure. Results  We included 46 patients, of which 41 were female and 5 were male. Before the bariatric procedure, these patients had an average maximum weight of 121.4 kg and an average maximum body mass index of 45.78 kg/m 2 ; 7 were grade I obese patients, 10 were grade II, and 29 were grade III. Only three patients were operated on with a gastric sleeve and 43 with gastric bypass. We presented six patients with transitory intra-abdominal hypertension in the first 24 hours, all of them from the grade I obesity group, the highest presented was 14.3 mm Hg. We presented 15% (7/46) of complication rates, which were only four seroma and five dehiscence; two patients presented both seroma and wound dehiscence. Conclusion  Performing a 10-cm abdominal wall plication or greater represents a higher risk for intra-abdominal hypertension, slower general recovery, and possibly higher complication rate in patients who presented a lower degree of obesity (grade I) at the moment of the bariatric surgery.

Weight Control following Body Contouring Surgery: Long-Term Assessment of Postbariatric and Nonbariatric Patients

BACKGROUND

Few reports of weight maintenance following body contouring (BC) surgery present weight measurements as percentage weight change, and most of these studies do not isolate BC to specific body areas. This study analyzed weight control in the trunk-based BC population and further compared BC outcomes in postbariatric and nonbariatric patients.

METHODS

The authors performed a retrospective cohort study of consecutive postbariatric and nonbariatric patients who underwent trunk-based BC (abdominoplasty, panniculectomy, and circumferential lipectomy) from January 1, 2009, through July 31, 2020, at West Virginia University. A minimum 12-month follow-up was required for inclusion. With BC surgery date as the reference point, percentage total weight loss was assessed at 6-month intervals for 2 years following BC and every year thereafter. Change over time was compared between postbariatric and nonbariatric patients.

RESULTS

Within the 12-year timeframe, 121 patients meeting criteria underwent trunk-based BC. Average follow-up from date of BC was 42.9 months. Sixty patients (49.6%) had previously undergone bariatric surgery. From before BC to endpoint follow-up, postbariatric and nonbariatric patients experienced a 4.39% ± 10.93% and 0.25% ± 9.43% increase in weight from baseline, respectively ( P = 0.0273). Once nadir weight loss was attained, weight regain occurred through endpoint follow-up in both groups (11.81% in the postbariatric cohort and 7.56% in the nonbariatric BC cohort; P = 0.0106).

CONCLUSIONS

Long-term weight regain is common following trunk-based BC operations-specifically, in postbariatric patients. Although this should not contend with the psychological benefit of removing this excess tissue, it is important to report results with ideal weight metrics to optimally assess outcomes in this population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

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

BACKGROUND

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

METHODS

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

RESULTS A TOTAL OF

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

De-epithelialized Dermal Flap to Reduce Sacral Wound Healing Complications After Lower Body Lift Procedure

BACKGROUND

Lower or circumferential body lift procedures in the massive-weight-loss population have been associated with significant complication rates. Particularly, the sacral area is at risk of wound-healing problems due to high wound tension or shear forces.

OBJECTIVES

The authors introduced a de-epithelialized dermal flap to reinforce the sacral area.

METHODS

Within this retrospective study, outcomes of 40 consecutive patients who underwent lower body lift between 2017 and 2021 were analyzed. The patient population was divided into 2 study groups (sacral flap vs no flap) including 20 patients each. Demographic and surgical data as well as complications were evaluated and compared. Appropriate statistical analysis was performed.

RESULTS

Thirty-seven female and 3 male patients with a median age of 36.5 years (range, 23-54 years) and a mean weight loss of 46.3 ± 12 kg participated in the study. The most common complication was sacral wound dehiscence (n = 7, 17.5%), and its occurrence was statistically significantly lower in the sacral flap group (P = 0.037). The odd ratios for complications when executing the sacral flap procedure were reduced to 0.306 (95% confidence interval = 0.075 to 1.246) and 0.261 (95% confidence interval = 0.055 to 1.250) for the uncorrected and corrected logistic regressions, respectively. In addition, findings showed a significantly shorter hospital stay as well as statistical trends towards a lower occurrence of overall complications in the sacral flap group. Concerning the remaining data, no statistically significant differences between study groups were detected.

CONCLUSIONS

The presented de-epithelialized dermal flap leads to a significant reduction of sacral wound-healing complications and a shorter hospital stay for patients. This surgical technique is easily reproduceable, rapid, and effective; therefore, we would recommend it for each circumferential or lower body lift procedure.

LEVEL OF EVIDENCE: 4

[Factors influencing the changed Quality of Life after postbariatric Abdominoplasty]

INTRODUCTION

The improvement of health-related quality of life (HRQoL) via post-bariatric tightening operations and their effects on long term weight stability is considered to be ensured. This study investigates the relevancy of influencing factors.

PATIENTS, MATERIAL AND METHODS

For the data analysis, the HRQoL was ascertained before and after the abdominoplasty using the 36-Item Short-Form Health Survey questionnaire. In addition, the occurrence frequency of bloating-symptoms was recorded. It was checked whether this occurrence was related to a rectus plication simultaneously performed with the abdominoplasty. Inclusion criterion was obesity ≥ I° prior to the weight loss. Exclusion criteria were a postoperative, newly manifested and serious disease, as well as a pregnancy during the observation period. The results were compared to the German population (standard).

RESULTS

The postoperative HRQoL was significantly improved as far as the physical healthscale (KSK) is concerned (preOP: 40,19 ± 12,27; postOP: 47,72 ± 9,89; p < 0,001). Preoperatively, the KSK and the PSK (psychological health scale) were statistically significant below the value of the normal population (KSK: p < 0,001; PSK: p < 0,01). There were no significant differences postoperatively (KSK: p = 0,051; PSK: p = 0,118). Patients on which an additional rectus plication was performed (n = 9) suffered significantly more often from bloating-symptoms than patients without this surgical step (n = 21) (p < 0,05). Patients with bloating-symptoms < 4/W (vs > 4/W) had a significantly better vitality (< 4/W: 61,09 ± 24,95; > 4/W: 34,29 ± 21,49; p < 0,05) and a better general health (< 4/W: 68,04 ± 23,23; > 4/W: 44,71 ± 27,8; p < 0,05). Compared to the standard, patients with bloating-symptoms > 4/W had a poorer vitality (p < 0,05).

CONCLUSION

Based on the analysis, a postoperative improvement of the HRQoL in the formerly obese can be assumed. It can also be predicated that there is a postoperative adjustment of the HRQoL compared to that of the German population. Furthermore, a rectus plication that is performed in addition to the abdominoplasty more frequently leads to bloating-symptoms, which, in turn, worsen the HRQoL. The diagnosis of a depressive disorder is a good predictor for a worse HRQoL outcome.

Healthcare delivery and information provision in bariatric surgery in Germany: qualitative interviews with bariatric surgeons

Background

There are several healthcare professionals involved in health information provision regarding bariatric surgery, such as bariatric surgeons, nutritionists, and medical doctors in outpatient settings. Trustworthy health information supports patients in understanding their diagnosis, treatment decisions, and possible prognosis. Therefore, it is necessary to provide health information on bariatric surgery. This study has two distinct objectives. The first is to outline the delivery of healthcare regarding bariatric surgery in Germany. The second is to describe the information provision within healthcare delivery.

Methods

We conducted 15 semi-structured telephone interviews with bariatric surgeons between April 2018 and February 2019. The interviews were audio recorded and transcribed verbatim. The interview guide consisted of four sections (information about the clinic/surgeon and surgical procedures, preoperative procedure, postoperative procedure, information needs). The transcribed interviews were analyzed using qualitative content analysis supported by MAXQDA software.

Results

The pre- and postoperative processes differed substantially between clinics. Additionally, every bariatric clinic had its own information provision concept. There were several cost-related issues the surgeons claimed to be relevant for patients, such as nutritional blood tests or postoperative psychotherapy. These issues were often caused by unclearness of responsibility within the medical disciplines involved.

Conclusion

Healthcare delivery in bariatric surgery in Germany is heterogeneous in terms of pre- and postoperative care. Therefore, preoperative information provision between the clinics differs. The impact of this heterogeneous healthcare delivery and information provision on patients’ information needs regarding bariatric surgery should be further investigated among patients and other healthcare professionals involved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06629-4.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE III

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

The Edmonton Obesity Staging System as a predictor for postoperative complications after medial thigh lift in massive weight loss patients

BACKGROUND

This study investigates the correlation between the Edmonton Obesity Staging System (EOSS) and the occurrence of postoperative complications after medial thigh lift in formerly obese patients.

PATIENTS AND METHODS

A single-institution retrospective review of patients undergoing medial thigh lift between 2009 and 2019 after massive weight loss. Data on demography, comorbidities, surgery, and postoperative outcome were extracted from patients' charts. Patients were grouped into EOSS categories. Complications were classified into minor and major. Logistic regression analysis was performed to determine the association between risk factors and complications.

RESULTS

One hundred and eight patients were included in the study. Complications occurred in 76 (70%) of the patients, most of which were minor (60/108, 56%). Complications increased with increasing EOSS stage, and all EOSS 3 patients had complications. Classification as EOSS 2 or 3 significantly associated with occurrence of postoperative complications (OR 99.3, p<0.001) as well as minor and major complications individually (OR 3.1 and 6.5, p<0.05). This effect was independent of body mass index (BMI), maximum BMI loss, type of weight loss, volume of liposuction, weight of resected tissue, and type of surgery.

CONCLUSION

EOSS is a robust and independent predictor for postoperative complications in medial thigh lift surgery after massive weight loss.

Long-Term Weight Loss with Body Contour Surgery After Roux-en-Y Gastric Bypass

BACKGROUND

Bariatric surgery is accepted as an evidence-based treatment for morbid obesity. Many patients seek out body contour surgery afterwards to correct acquired deformities. This study seeks to better define the impact of body contour surgery on long-term weight loss.

METHODS

This study is a single-center retrospective review of 78 patients who underwent body contouring surgery post-Roux-en-Y gastric bypass compared with 221 matched control patients who underwent Roux-en-Y gastric bypass only. Data was collected for patients at least 7 years post-Roux-en-Y gastric bypass.

RESULTS

Patients who underwent both bariatric surgery and body contour surgery maintained mean long-term weight loss of 58 kg. The matched control group mean weight loss over the same time interval was 42 kg. The difference was statistically and clinically significant (p = 0.005). Change in body mass index, percent total weight loss, and percent excess body mass index loss were all statistically significant between the 2 groups.

CONCLUSION

Patients who underwent body contour surgery better maintained long-term weight reduction in comparison to those who only had gastric bypass. Further understanding of the etiology of this association is important for patients contemplating body contouring surgery.

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

Introduction

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Body Contouring Surgery Improves Physical Activity in Patients After Massive Weight Loss-a Retrospective Study

BACKGROUND

The aim of the study was to compare physical activity (PA) in patients who had undergone massive weight loss (MWL), before and after body contouring procedures.

METHODS

All patients undergoing body contouring surgery after MWL between 2007 and 2017 with a minimum follow-up of 6 months after the last procedure were included in this retrospective study. Excluded were those with a body mass index > 35 kg/m² and those with comorbidities leading to impaired PA. Quality of life (QOL) was assessed using the Moorehead-Ardelt QOL Questionnaire II. Evaluation of PA was obtained with the International Physical Activity Questionnaire (IPAQ) short form and the Freiburg PA Questionnaire. Functional impairment during exercise was analyzed using a self-designed functional impairment score (FIS).

RESULTS

In the 45 patients completing the survey (37 female, 8 male), an improvement in QOL (p < 0.001) and PA scored by the IPAQ (p = 0.017) was found. The Freiburg PA Questionnaire showed no difference in PA before and after body contouring surgery (p = 0,274). Furthermore, scores of the FIS indicated a decrease of functional impairment during physical activity after body contouring surgery (p < 0.001).

CONCLUSION

Body contouring improves QOL and PA in patients after massive weight loss. The results of our study confirm the important role of plastic surgery in the treatment and maintenance of health of patients with former obesity.

The PRS Rainbow Classification for Assessing Postbariatric Contour Deformities

Supplemental Digital Content is available in the text.

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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.

The BAPRAS screening tool for reimbursement in a postbariatric population

INTRODUCTION

Reimbursement of body-contouring surgery (BCS) is a worldwide problem: there is no objective instrument to decide which postbariatric patients should qualify for reimbursement. The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) has developed a screening tool for this purpose. In this study, we used a modified version of this screening tool in a postbariatric population and describe which patients would qualify for reimbursement using this tool.

METHODS

In this cross-sectional study postbariatric patients were asked to fill in an online questionnaire based on the BAPRAS screening tool with questions regarding complaints of overhanging skin and medical history. Weight loss data were extracted from a prospective database. The BODY-Q was added to assess patient-reported outcomes.

RESULTS

Patients who wanted to undergo BCS (n = 90) had higher screening tool scores and lower BODY-Q scores compared to patients who did not want BCS (n = 24). In total, 25 patients (26%) qualified for reimbursement, these patients had higher weight loss (33.5% versus 29.2%, p = 0.008), lower BMI (27.3 kg/m² versus 30.4 kg/m², p = 0.014) and more medical (4.0 versus 2.0, p = 0.004) and psychological complaints (88% versus 61%, p = 0.009). There was a significant, negative correlation between the screening tool scores and almost all BODY-Q scales.

CONCLUSIONS

Patients with a desire for BCS have more complaints of excess skin, which negatively impacts their well-being. With the modified BAPRAS screening tool, patients with the best weight (loss) and most medical and psychological complaints of excess skin qualified for referral and reimbursement of BCS.

The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

Introduction

There has been a significant increase in the number of body contouring procedures performed worldwide. This study aimed to evaluate the long-term psychosocial effects of these procedures among patients who undergone weight loss surgery and maintained their body mass for a minimum of one year.

Material and methods

Post-bariatric patients undergoing body contouring procedures were recruited for the study consecutively. Inclusion criteria: BMI < 30 following bariatric surgery, weight maintenance for a minimum of 12 months, and completion of all follow up questionnaires (6 and 12 months). Patients were surveyed 24 hours before, 6-months, and 12-months post-procedure using a Polish validated version of BODY-Q.

Results

30 consecutive patients with a mean age of 38 years (SD 5,91) were included in this study. The BODY-Q questionnaire revealed statistically significant improvements in the acceptance of body appearance after 12 months of follow up. In the abdominal area, the rise in scores achieved 90 from the starting level of 13, and the overall body image increased from 24 to 67. Moreover, in patients with postoperative complications (one hematoma and four minor wound dehiscence), the overall score did not differ from uncomplicated patients.

Conclusions

Body contouring procedures after massive weight loss significantly improve the general perception of personal appearance as well as both the psychological and social aspects of life in patients, already significantly stigmatized by their appearance. Body contouring procedures have essential value and should be widely offered as a step in the treatment of morbidly obese patients.

The Impact of Post-bariatric Abdominoplasty on Secondary Weight Regain After Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB), implies a considerable weight loss during the first two years after surgery. Excess skin due to rapid weight loss might affect self-esteem, decrease quality of life and be a hindrance to physical activity. Removing excess skin might reduce secondary weight regain. Among plastic surgeons, a BMI <30 kg/m² is usually required to have abdominoplasty (AP). Many RYGB patients never reach this threshold even if they have a considerable weight loss and experience practical as well as emotional problems due to excess skin. The aim of this study was to investigate the role of abominoplasty on weight development until five years, among patients who did and did not achieve a nadir BMI <30 kg/m² during the first two years after RYGB. Data on 645 patients from a single center RYGB-quality register from 2004 to 2013 with baseline and follow-up data were analyzed. Post-bariatric AP was publicly funded if medically needed. Weight regain (WR) from nadir weight to five years was analyzed as percentage WR of maximal weight loss. Nadir BMI was available in 633 (98.1%) patients, and BMI after five years in 553 (85.7%) patients. The 233 patients with nadir BMI <30 kg/m² who underwent AP regained 17.8 (±16.1) % of their maximal weight loss at five years compared to 24.2 (±19.7) % in 185 patients not having AP (p < 0.001). The 27 patients with nadir BMI > 30 kg/m² within two years after RYGB who underwent AP regained 12.9 (±19.3) % compared to 31.4 (±24.7) % in 188 patients without AP (p < 0.001). This procedure was more common among women than men, as 224 (46.4%) women, and 36 (22.2%) men underwent AP. Abdominoplasty was associated with reduced secondary weight regain after RYGB in this study. Whether this is caused by increased bodily satisfaction and better physical function, or a biological response to reduction of adipose tissue remains unclear. If removing abdominal subcutaneous adipose tissue prevent secondary weight regain and increase the robustness of bariatric surgery, this should be offered as part of the standard treatment after bariatric surgery.

Body contouring in adolescents after bariatric surgery

BACKGROUND

Bariatric surgery leads to sustained weight loss and resolution of obesity-associated co-morbidities in severely obese adolescents. However, one consequence of massive weight loss is excess skin and soft tissue. Many details regarding the timing, outcomes, and barriers associated with body contouring surgery (BCS) in youth who have undergone bariatric surgery are unknown.

OBJECTIVES

Describe the incidence and effect of BCS following bariatric surgery among adolescents.

SETTING

University Hospitals.

METHODS

Teen-Longitudinal Assessment of Bariatric Surgery is a prospective multi-institutional study of 242 adolescents who underwent bariatric surgery from 2007 to 2012. Utilization of BCS was analyzed in this population with comparison of anthropometrics and excess skin-related symptoms between those who did and those who did not undergo BCS.

RESULTS

Among the 198 study participants with BCS data available, 25 (12.6%) underwent 41 body contouring procedures after bariatric surgery. The most common BCS was panniculectomy (n = 23). Presence of pannus-related symptoms at baseline and the magnitude of weight loss within the first year after bariatric surgery were independently associated with subsequent panniculectomy (P = .04 and P = .03, respectively). All adolescents who underwent panniculectomy experienced resolution of pannus-related symptoms. At 5 years after bariatric surgery, 74% of those who did not undergo panniculectomy reported an interest in the procedure, and 58% indicated that cost/insurance coverage was the barrier to obtaining BCS.

CONCLUSION

Few adolescents who underwent bariatric surgery later underwent BCS procedures. Panniculectomy effectively treated pannus-related symptoms. Disparities in access to surgical care for adolescents who desire BCS warrants further investigation.

Clinical outcome of patients undergoing abdominoplasty after massive weight loss

BACKGROUND

Abdominoplasty is one of the most commonly performed surgical procedures to reshape the body contour in patients who have undergone massive weight loss.

OBJECTIVES

This study was undertaken to assess the clinical outcome, complication rates, and risk factors for complications of patients undergoing abdominoplasty after massive weight loss.

SETTING

University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

METHOD

Clinical outcome was retrospectively analyzed in 121 patients, who underwent abdominoplasty. The retrospective analysis included demographic data of patients, such as sex, age, body mass index (BMI), and pre-existing illnesses. Moreover, postoperative complications including seroma, hematoma, wound infection, and tissue necrosis were analyzed.

RESULTS

In our study cohort, the median age was 43.7 years, the median weight was 94.7 kg, and the median BMI was 32.3 kg/m². The majority of included patients were women (70.3%). Death occurred in none of the patients. Among individuals, wound infection occurred in 3.3%, tissue necrosis in 1.7%, seroma in 7.4%, and hematoma in 3.3% of patients during the postoperative course. Reoperations were necessary in 2 patients (1.7%) due to postoperative bleeding and tissue necrosis of the navel. Tissue necrosis was significantly more often seen in a subset individual with type 2 diabetes (P = .006). Moreover, the rate of reoperations was significantly higher in patients with pre-existing cardiovascular illnesses compared with cardiovascular healthy patients (P = .036). Multivariate analysis analyzing risk factors for postoperative complications, including sex, age, BMI, diabetes, pulmonary disease, and cardiovascular disease, revealed strong independent relevance for type 2 diabetes (P = .024).

CONCLUSIONS

We found that abdominoplasty is a safe operative procedure. In addition, the risk for complications is significantly increased in the subgroup of diabetic patients and patients with cardiovascular diseases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ligasure impact™might reduce blood loss, complications, and re-operation occurrence after abdominoplasty in massive-weight-loss patients: A Comparative Study

Background and Aims:

The most effective dissection technique for raising the flap in abdominoplasty is still controversial, particularly in high-risk massive-weight-loss patients. LigaSure Impact™vessel-sealing system (Medtronic, Dublin, Ireland) is an energy device commonly used among different surgical specialties to reduce morbidity and implement outcomes. The aim of this study was to investigate the effectiveness of LigaSure Impact in abdominoplasty compared with the conventional techniques, diathermia.

Material and Methods:

Patients underwent primary abdominoplasty after massive weight loss at a single center from 1 January 2008 to 31 May 2015 and were retrospectively reviewed. A total of 94 patients eligible for the study were divided into two groups on basis of the dissection technique: LigaSure Impact group (29 patients) and the conventional technique group (65 patients). Total intraoperative blood loss was the primary endpoint. Duration of the operation, perioperative complications and re-operation were recorded as secondary endpoints.

Results:

Baseline characteristics were well balanced between the groups. Significant differences were found in intraoperative blood loss favoring LigaSure Impact group (259.6 ± 198.8 mL vs 377.9 ± 190.0 mL, p = 0.004) and blood transfusion rates (13.8% vs 35.4%, p = 0.047). In contrast, operative time was significantly longer in LigaSure Impact group (168.6 ± 121.2 vs 179.7 ± 57.6 min, p = 0.005), while a tendency to shorter hospital stay was found in LigaSure Impact group (3.6 ± 1.1 days vs 4.6 ± 3.2 days, p = 0.081). Overall complications occurrence, Clavien–Dindo grade II (24.1% vs 55.4%) and grade III (13.8% vs 30.8%) complications were significantly lower in LigaSure Impact group (respectively, p = 0.005, p = 0.007, p = 0.016). Late (>30 days) re-operation rate was significantly lower in the LigaSure Impact group (6.9% vs 27.70%, p = 0.0028). Specific wound complications showed no significant difference.

Conclusion:

LigaSure Impact vessel-sealing system may be beneficial in improving abdominoplasty outcomes in massive-weight-loss patients because it might reduce blood loss, need for transfusions, complications, and re-operations.

Using the BODY-Q to Understand Impact of Weight Loss, Excess Skin, and the Need for Body Contouring following Bariatric Surgery

BACKGROUND

A consequence of bariatric surgery is redundant skin for most patients. The authors measured health-related quality of life and appearance following bariatric surgery in relation to weight loss, excess skin, and need for body contouring.

METHODS

The sample included Canadian participants from the BODY-Q field-test study recruited between November of 2013 and July of 2014. Participants were invited to complete BODY-Q scales and questions to assess weight loss, amount of excess skin, and need for body contouring between June 7, 2016, and November 29, 2016.

RESULTS

Two hundred fourteen participants responded (75 percent response rate). Of the 210 who underwent bariatric surgery, most were left with excess skin [n = 196 (93 percent)] and needed body contouring [n = 168 (80 percent)]. Higher percentage total weight loss correlated with more excess skin (r = 0.24, p = 0.001), the need for more body contouring procedures (r = 0.29, p < 0.001), and (worse) scores on seven of 13 BODY-Q scales. Having redundant skin correlated with more physical symptoms (r = 0.31, p < 0.001), the need for more body contouring procedures (r = 0.62, p < 0.001), and lower scores on 12 BODY-Q scales. The need for more body contouring procedures correlated with more physical symptoms (r = 0.23, p = 0.001) and lower scores on 12 BODY-Q scales.

CONCLUSIONS

Excess skin after bariatric surgery is a disabling problem. Additional research using the BODY-Q is needed to determine improvements that can be achieved following body contouring.

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.

Body image dissatisfaction and depression in postbariatric patients is associated with less weight loss and a desire for body contouring surgery

BACKGROUND

Overhanging skin in postbariatric patients leads to a negative body image. In patients with obesity, negative body image is related to more depressive symptoms and a higher weight. This relationship might also be important in postbariatric patients, because improvement of body image via body contouring surgery (BCS) could lead to better weight loss results.

OBJECTIVES

To evaluate the relationship between body image, depressive symptoms, and weight loss in a postbariatric population, focusing on desire for BCS.

SETTING

Outpatient clinic.

METHODS

One thousand twenty-four primary bariatric surgery patients were contacted, and 590 patients agreed to participate and filled in online questionnaires regarding body image (Body Shape Questionnaire and Multidimensional Body-Self Relations Questionnaire-Appearance Scales) and depression (Beck Depression Inventory-II). Differences between patients who had BCS, patients who desired BCS, and patients who did not desire BCS were studied. The mediating role of body image in the association between percentage total weight loss and depressive symptoms was assessed via a 2-mediator model.

RESULTS

There was a desire for BCS in 368 patients (62.4%); these patients had significantly lower scores on appearance evaluation and body image satisfaction scales and showed more depressive symptoms. Patients without a desire (n = 157, 26.6%) had lowest rates of depressive symptoms and a more positive body image. Sixty-five patients (11.0%) had undergone BCS. In the patients who desired BCS, percentage total weight loss was negatively affected by depressive symptoms via appearance evaluation and body-area satisfaction.

CONCLUSIONS

There are striking differences regarding body image satisfaction and depressive symptoms when comparing postbariatric patients and without desire for BCS. Body image satisfaction is associated with less depressive symptoms in all postbariatric patients. In patients who desired BCS, body image is one of the mediators of the relationship between percentage total weight loss and depressive symptoms. Therefore, body image should be taken seriously and be part of outcome assessment in postbariatric patients.

Body Contouring Surgery and the Maintenance of Weight-Loss Following Roux-En-Y Gastric Bypass: A Retrospective Study

BACKGROUND

Bariatric surgery leads to significant weight loss with reduced morbidity and mortality. However, excess skin as a consequence of weight loss represents a major problem, impacting upon patient's functionality with potential negative effects on weight loss.

OBJECTIVES

We evaluated the effect of body-contouring surgery on weight-loss maintenance following bariatric surgery.

METHODS

We undertook a retrospective analysis of patients undergoing Roux-en-Y gastric bypass (RYGB) +/- body-contouring surgery (BC). The control group (n = 61) received RYGB, the test group (n = 30) received RYGB+BC 12 to 18 months after bariatric surgery. Each RYGB+BC patient was matched to two control patients for age, sex, glycaemic status, and weight on day of surgery. Per cent weight loss (%WL) was calculated at 3, 6, 12, 24, 36, 48, and 60 months post-RYGB for both groups.

RESULTS

The %WL was similar at 3, 6, and 12 months post-RYGB. At 24 months, %WL was 35.6% in the RYGB+BC group and 30.0% in the RYGB group (P < 0.05). At 36 months, the RYGB+BC group maintained their weight loss (%WL 33.0%), in contrast, the RYGB gained weight (%WL = 27.3%, P < 0.05). This trend continued (RYGB+BC vs RYGB) at 48 months (%WL 30.8% vs 27.0%) and at 60 months (%WL 32.2% vs 22.7%, P < 0.05).

CONCLUSIONS

Our results suggest patients who undergo body contouring after bariatric surgery are able to lose significantly more weight and maintain weight loss at five years of follow up compared to those undergoing bariatric surgery alone.

Autologous Flap Gluteal Augmentation: Purse-String Technique

The ideal patient for purse-string gluteoplasty has buttock deflation and ptosis, and wishes to improve projection. Key elements of the procedure are buttock lifting combined with auto-augmentation, no undermining of auto-augmentation tissue, and use of a purse-string suture to enhance projection of auto-augmentation tissue. Purse-string gluteoplasty is a safe and effective technique to correct buttock ptosis and atrophy.

Body Contouring After Massive Weight Loss: A Personal Integrated Approach

BACKGROUND

After massive weight loss, patients typically presented with skin redundancy, which causes enormous esthetic, physical, medical and psychological problems. The growing number of patients with these sequelae triggered an increase in the search for body contouring procedures, which in turn produced an important development in the post-bariatric reconstructive surgery.

METHODS

The author describes the principles of a personal approach in post-bariatric reconstructive surgery. The concept is based on an integrative approach, attending to multiple anatomic segments in the same procedure, associated with multiple refinements of the surgical technique. A retrospective study was carried out, including all body contouring procedures in massive weight loss patients performed by the author between January 2009 and December 2013.

RESULTS

The sample is comprised of 74 patients, in a total of 120 surgeries, of which 70% were performed on the pelvic girdle and 30% on the scapular girdle. The most common complication noted by the author was small wound dehiscence. In 2011, the author began performing Pollock´s technique in abdominoplasty, with fixation stitches to the deep planes, and double-layer sutures, instead of single intra-dermal suture. At the same time, he stopped using drains. Interestingly, the rate of complications, including hematoma, proved to be lower in this group of patients.

DISCUSSION

The application of this integrated post-bariatric surgery concept enables multiple anatomic segment contouring in less surgical procedures, which in turn permits a more immediate final result, associated with lower hospitalization times and lower complication rates.

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 .

Gluteal Implants Versus Autologous Flaps in Patients with Postbariatric Surgery Weight Loss: A Prospective Comparative Study of 3-Dimensional Gluteal Projection After Lower Body Lift

BACKGROUND

Deformities and excess skin resulting from massive weight loss are corrected with circumferential lower body lift (LBL). The gluteal area is frequently flattened due to aggressive skin excision during LBL. Gluteal implants can circumvent this problem.

OBJECTIVES

We aimed to objectively evaluate the outcomes of gluteal augmentation with implants versus flap surgery performed simultaneously with LBL.

METHODS

Between January 2014 and June 2015, twenty-seven patients underwent LBL with gluteal implants (10 patients), flaps (14 patients), or no gluteal augmentation (3 patients) in our hospital. Three-dimensional analysis was used to assess gluteal projection preoperatively and at 6 months. Gain in projection, pain scores, complications, and patient and surgeon satisfaction were compared.

RESULTS

The mean follow-up duration was 18 months. The mean gain in projection at 6 months was 4.9 mm in the implant group, -0.5 mm in the flap group (P = 0.1), and -9.6 mm in the control group. The mean implant volume was 294.5 mL. Operation time was shorter in the flap group (192 min) than in the implant group (218 min, P = 0.001). Surgeon satisfaction was higher in the implant group (P = 0.007). Implants were more painful than flaps at 4 days and 2 weeks (P = 0.004 for both). There were 6 minor complications (60%) in the implant group versus 7 (50%) in the flap group (P = 0.94).

CONCLUSIONS

In selected patients, LBL with gluteal implants is safe and slightly increases gluteal projection.

LEVEL OF EVIDENCE

2.

Absence of an Additional Metabolic Effect of Body Contour Surgery in Patients With Massive Weight Loss After Laparoscopic Roux-En-Y Gastric Bypass

INTRODUCTION

Body contour surgery (BCS) is a combination of soft tissue resections that have proven to be an effective treatment for the aesthetic and functional problems related to massive weight loss (MWL). There are no studies analyzing the metabolic effect of large volume adipose tissue flap resection in patients with MWL after bariatric surgery.

METHODS

This study was a retrospective review of adults who underwent BCS after gastric bypass. Preoperative clinical and laboratory data were compared with 1- and 2-year postoperative follow-up.

RESULTS

A total of 62 patients with a mean age of 41 years were analyzed. Seventy-nine percent of them were women. Most procedures included abdominal flap resection alone or in combination with other areas. Mean resected tissue weight was 6.2 kg. We found that weight and body mass index (BMI) were lower 1 year after BCS (P < 0.05), but this was not maintained after 2 years. There were no differences for systolic or diastolic blood pressure, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, or fasting glucose after 1 and 2 years of the BCS. A subgroup analysis showed that the transient weight and BMI improvement was only apparent 1 year after BCS in those patients with flap resections more than 8 kg.

CONCLUSIONS

There are no differences in blood pressure, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, or fasting glucose 1 and 2 years after BCS in patients who experienced MWL after gastric bypass. Although weight and BMI were transiently lower in those patients with tissue flap resections more than 8 kg, this effect disappeared after 2 years.

Body contouring procedures in three or more anatomical areas are associated with long-term body mass index decrease in massive weight loss patients: A retrospective cohort study

BACKGROUND

Massive weight loss (MWL) patients who undergo body contouring plastic surgery (BCPS) display superior long-term weight maintenance. The effect of the number of anatomical areas contoured on weight dynamics is undetermined.

OBJECTIVES

To determine whether body mass index (BMI) dynamics following BCPS are associated with the number of anatomical areas operated.

METHODS

A retrospective cohort study was conducted. Study groups were defined by the number of anatomical areas operated (1, 2, and 3+). BMI velocity was defined as a ratio between BMI change following BCPS and follow-up time. Multinomial logistic regression was performed to assess the independent association with BMI velocity.

RESULTS

A total of 222 patients undergoing 513 BCPSs between 2009 and 2014 were included in the study (mean age 36.8 ± 10.9 years, 77% females). Group 3+ (n = 88) had a negative mean BMI velocity compared with positive values in Groups 1 and 2 (-0.11 ± 1.0 vs. 0.44 ± 1.4 and 0.03 ± 1.2, respectively; p = 0.03). Independent risk factors for positive BMI velocity (>0.5 kg/m²/year) included single anatomical area BCPS compared to three or more (OR = 3.37; CI 95% 1.24-9.14; p = 0.017) and psychiatric medication use (OR = 6.73; CI 95% 1.15-39.35; p = 0.034). Independent protective factors included diabetes mellitus (OR = 0.094; CI 95% 0.01-0.99; p = 0.049).

CONCLUSIONS

BCPS in three or more anatomical areas following MWL is associated with a long-term weight loss following BCPS. As part of the health strategy to maintain normal BMI values and achieve overall quality of life improvement in MWL patients, clinicians and health policy makers should positively consider recommending BCPS in multiple anatomical areas.

Introducing the Body-QoL®: A New Patient-Reported Outcome Instrument for Measuring Body Satisfaction-Related Quality of Life in Aesthetic and Post-bariatric Body Contouring Patients

OBJECTIVE

To develop a new patient-reported outcome instrument (PRO) to measure body-related satisfaction quality of life (QoL).

METHODS

Standard 3-phase PRO design was followed; in the first phase, a qualitative design was used in 45 patients to develop a conceptual framework and to create preliminary scale domains and items. In phase 2, large-scale population testing on 1340 subjects was performed to reduce items and domains. In phase 3, final testing of the developed instrument on 34 patients was performed. Statistics used include Factor, RASCH, and multivariate regression analysis. Psychometric properties measured were internal reliability, item-rest, item-test, and test-retest correlations.

RESULTS

The PRO-developed instrument is composed of four domains (satisfaction with the abdomen, sex life, self-esteem and social life, and physical symptoms) and 20 items in total. The score can range from 20 (worst) to 100 (best). Responsiveness was 100 %, internal reliability 93.3 %, and test-retest concordance 97.7 %. Body image-related QoL was superior in men than women (p < 0.001) and decreased with increasing age (p = 0.004) and BMI (p < 0.001). Post-bariatric body contouring patients score lower than cosmetic patients in all domains of the Body-QoL instrument (p < 0.001). After surgery, the score improves by on average 21.9 ± 16.9 (effect size 1.8, p < 0.001).

CONCLUSIONS

Body satisfaction-related QoL can be measured reliably with the Body-QoL instrument. It can be used to quantify the improvement in cosmetic and post-bariatric patients including non- or minimally invasive procedures, suction assisted lipectomy, abdominoplasty, lipoabdominoplasty, and lower body lift and to give an evidence-based approach to standard practice.

LEVEL OF EVIDENCE I

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.

Panniculectomy Combined with Bariatric Surgery by Laparotomy: An Analysis of 325 Cases

Surgical treatment of obese patients is much debated in the literature because of the significant intraoperative risks related to comorbidities presented by this type of patients. Recent literature suggests that panniculectomy should follow bariatric surgery after the patient's weight loss has been stabilized. However, when performed by laparotomy, bariatric surgery can be combined with panniculectomy. This paper presents the analysis of 325 cases of patients undergoing abdominal panniculectomy combined with bariatric surgery. The study highlights the risks, complications, and benefits of the combined procedure and describes a standardized technique for excision of a large abdominal panniculus in a short operating time.

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.

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.

Body image and quality of life in patients with and without body contouring surgery following bariatric surgery: a comparison of pre- and post-surgery groups

Background: Massive weight loss (MWL) following bariatric surgery frequently results in an excess of overstretched skin causing physical discomfort and negatively affecting quality of life, self-esteem, body image, and physical functioning.

Methods: In this cross-sectional study 3 groups were compared: (1) patients prior to bariatric surgery (n = 79), (2) patients after bariatric surgery who had not undergone body contouring surgery (BCS) (n = 252), and (3) patients after bariatric surgery who underwent subsequent BCS (n = 62). All participants completed self-report questionnaires assessing body image (Multidimensional Body-Self Relations Questionnaire, MBSRQ), quality of life (IWQOL-Lite), symptoms of depression (PHQ-9), and anxiety (GAD-7).

Results: Overall, 62 patients (19.2%) reported having undergone a total of 90 BCS procedures. The most common were abdominoplasties (88.7%), thigh lifts (24.2%), and breast lifts (16.1%). Post-bariatric surgery patients differed significantly in most variables from pre-bariatric surgery patients. Although there were fewer differences between patients with and without BCS, patients after BCS reported better appearance evaluation (AE), body area satisfaction (BAS), and physical functioning, even after controlling for excess weight loss and time since surgery. No differences were found for symptoms of depression and anxiety, and most other quality of life and body image domains.

Discussion: Our results support the results of longitudinal studies demonstrating significant improvements in different aspects of body image, quality of life, and general psychopathology after bariatric surgery. Also, we found better AE and physical functioning in patients after BCS following bariatric surgery compared to patients with MWL after bariatric surgery who did not undergo BCS. Overall, there appears to be an effect of BCS on certain aspects of body image and quality of life but not on psychological aspects on the whole.