Sahlgrenska Excess Skin Questionnaire (SESQ): A reliable questionnaire to assess the experience of excessive skin after weight loss

"Normal" breast dimensions in obese women-reference values and the effect of weight loss

BACKGROUND

Breast hypertrophy may cause significant suffering, such as back- and breast pain, painful shoulder groves, and eczemas. Furthermore, women with breast hypertrophy may have lower quality of life than women without breast hypertrophy. Although 50% of the women undergoing breast reduction in the US have body mass index (BMI) >30 kg/m2, the current standard of normality is based on studies focusing on women <40 years of age and BMIs <25 kg/m2. This study aimed to present reference values for breast measurements for women with obesity and to investigate the relationship between BMI loss and each breast measurement.

MATERIALS AND METHODS

One hundred and six women underwent laparoscopic Roux-en-Y gastric bypass in Gothenburg, Sweden. The participants' breast anthropometrics were measured before and after bariatric surgery and their perception of the skin on their breasts was measured using the Sahlgrenska Excess Skin Questionnaire.

RESULTS

Breast volume, sternal notch to nipple (SNN) distance, and ptosis increased significantly with increasing BMI. For instance, women with BMIs between 30-34.9 kg/m2 have a mean breast volume of approximately 770 ml, those with BMIs of 40-44.9 kg/m2 have approximately 1150 ml, and those with BMIs above 50 kg/m2 have approximately 1400 ml. Furthermore, the percent change in the respective breast measurements relative to percent BMI change can be predicted, for instance, with a 20% reduction in BMI, the breast volume, SNN-distance, and ptosis decrease by 25%, 4%, and 20% respectively.

CONCLUSIONS

This article presents the first standard of normality for breast anthropometrics in women with obesity and a model for predicting the change in breast anthropometrics relative to BMI.

CLINICAL TRIAL REGISTRATION

This is a longitudinal observation study, registered https://fou.nu/is/gsb/ansokan/49651, No: VGFOUGSB-49651. Trial registry name: "Överskottshud efter överviktskirurgi - dess utveckling samt behov och effekt av plastikkirurgi" ("Excess skin after bariatric surgery - its development and the need and effect of plastic surgery").

Factors Associated with Excess Skin After Bariatric Surgery: a Mixed-Method Study

PURPOSE

After metabolic and bariatric surgery (MBS), many patients have excess skin (ES), which can cause inconveniences. Identifying factors related to ES quantity and inconveniences is crucial to inform interventions. The aim of this study was to identify sociodemographic, physical, psychosocial, and behavioral factors associated with ES quantity and inconveniences.

MATERIALS AND METHODS

A mixed-method study with a sequential explanatory design was conducted with 124 adults (92% women, Mage 46.5 ± 9.9 years, Mtime post-MBS 34.2 ± 27.6 months). During phase I, ES quantity (arms, abdomen, thighs) and inconveniences and sociodemographic, anthropometric, clinical, and behavioral outcomes were assessed. In phase II, 7 focus groups were performed with 37 participants from phase I. A triangulation protocol was completed to identify convergences, complementarities, and dissonances from quantitative and qualitative data.

RESULTS

Quantitative data indicate only ES quantity on arms was associated with ES inconveniences on arms (r = .36, p < .01). Total ES quantity was associated with maximal body mass index (BMI) reached pre-MBS (r = .48, p < .05) and current BMI (r = .35, p < .05). Greater ES inconvenience was associated with higher social physique anxiety and age (R2 = .50, p < .01). Qualitative data were summarized into 4 themes: psychosocial experiences living with ES, physical ailments due to ES, essential support and unmet needs, and beliefs of ES quantity causes.

CONCLUSION

Measured ES quantity is related to higher BMI, but not reported inconveniences. Greater self-reported ES quantity and inconveniences were associated with body image concerns.

Determination of weight loss effectiveness evaluation indexes and establishment of a nomogram for forecasting the probability of effectiveness of weight loss in bariatric surgery: a retrospective cohort

BACKGROUND

The purpose of this research was to determine the index that contributes the most to assessing the effectiveness of weight loss 1 year following bariatric surgery and to implement it as the clinical outcome to develop and confirm a nomogram to predict whether bariatric surgery would be effective.

METHODS

Patient information was extracted from the Chinese Obesity and Metabolic Surgery Database for this retrospective study. The most contributing weight loss effectiveness evaluation index was created using canonical correlation analysis (CCA), and the predictors were screened using logistic regression analysis. A nomogram for estimating the likelihood of effectiveness of weight loss was constructed, and its performance was further verified.

RESULTS

Information was obtained for 540 patients, including 30 variables. According to the CCA, ≥25 percentage total weight loss was found to be the most correlated with patient information and contribute the most as a weight loss effectiveness evaluation index. Logistic regression analysis and nomogram scores identified age, surgical strategy, abdominal circumference, weight loss history, and hyperlipidemia as predictors of effectiveness in weight loss. The prediction model's discrimination, accuracy, and clinical benefit were demonstrated by the consistency index, calibration curve, and decision curve analysis.

CONCLUSIONS

The authors determined a 25 percentage total weight loss as an index for weight loss effectiveness assessment by CCA and next established and validated a nomogram, which demonstrated promising performance in predicting the probability of effectiveness of weight loss in bariatric surgery. The nomogram might be a valuable tool in clinical practice.

SESQ, a patient-reported outcome instrument addressing excess skin; report on the updated version and the validation process

Excess skin after weight loss is perceived as a major problem for the majority of the bariatric patients, between 68 and 90% desire additional reconstructive surgery. However, only about 20% of the patients actually have the possibility to undergo these procedures. Reliable and valid patient-reported outcome instruments, PROM, are required in order to consider the patients' perspective of excess skin when discussing reconstructive surgery. The aim of this study was to present the updated version of Sahlgrenska Excess Skin Questionnaire, SESQ and to report on the validation process. The material for the process to evaluate internal consistency and known group validity was based on four different studies conducted at the Department of Plastic Surgery at Sahlgrenska University Hospital, Sweden. Internal consistency was high in all four groups examined; the normal population, the obese patients, the post-bariatric patients and the post-abdominoplasty patients. Values for Cronbach's alpha were >0.86 in all groups, and the highest value was seen in the obese patients (0.92). Furthermore, regarding known group validity, there were strong significant differences between the answers from the normal population in comparison with most of the other studies. In conclusion, patients thought that the questions in SESQ were easy to understand, that they covered all appropriate aspects of excess skin and the patients did not think that SESQ overlooked any questions or aspects concerning excess skin. SESQ is a valid questionnaire addressing excess skin in post-bariatric patients. The updated version of the SESQ is both accurate and user-friendly.

Depressive symptoms before and after abdominoplasty among post-bariatric patients - a cohort study

The majority of post-bariatric patients suffer from excess skin after weight loss, impairing physical, psychosocial and mental health. The abdomen is the most common location for excess skin, and abdominoplasty is the most commonly required reconstructive procedure. Abdominoplasty removes excess abdominal skin and attenuates related symptoms, but knowledge regarding mental health-related effects is scarce. Here, we aimed to evaluate the symptoms and severity of depression before and after abdominoplasty in post-bariatric patients and to analyse the relationships between depressive symptoms, quality of life (QoL) and experience of excess skin. We enrolled 110 former obese patients undergoing abdominoplasty. Three questionnaires evaluating the symptoms of depression (Beck Depression Inventory (BDI-II)), experience of excess skin (Sahlgrenska Excess Skin Questionnaire (SESQ)) and QoL (36-item Short-Form Health Survey (SF-36)) were completed preoperatively and 1 year postoperatively. After abdominoplasty, symptoms of depression (BDI sum score) significantly decreased (5.8 vs. 3.0, p = .037). Scores on three BDI questions improved (p < .05), and the SESQ score normalised (p < .001), while the SF-36 score was unaffected. The BDI sum score was moderately correlated with the SF-36 mental composite score (preoperatively, r_s = -0.69; postoperatively, r_s = -0.66) and fairly correlated with the SF-36 physical composite score (r_s = 0.32, r_s = 0.26). The correlation between the BDI sum and SESQ scores was poor preoperatively (r_s = -0.106) and fair postoperatively (r_s = 0.232). The results indicate that abdominoplasty may reduce symptoms of depression in post-bariatric patients. However, the procedure did not affect SF-36 scores. Further studies are required to validate these results.

Translation and validation of a Swedish version of the BODY-Q: a patient-reported outcome instrument for weight loss and body contouring surgery

BODY-Q is self-administered questionnaire that evaluates appearance, function and symptoms related to bariatric- and body contouring surgery. The purpose of this article was to describe the translation process of a Swedish version of BODY-Q and to evaluate its criterion validity to the Swedish questionnaire Sahlgrenska Excess Skin Questionnaire, SESQ.

MATERIALS AND METHODS

BODY-Q was translated according to International Society for Pharmacoeconomics and Outcome Research's guidelines. The test of validity was made between parts which were comparable to SESQ. Both questionnaires were responded by 30 subjects who were suffering from excess skin after massive weight loss following bariatric surgery or dieting.

RESULTS

The correlation between the two questionnaires varied. The parts of BODY-Q evaluating excess skin on the whole body and parts of the body had higher correlations (r_s 0.328-0.766) than the parts evaluating side effects of excess skin and body-image (r_s 0.103-0.574).

CONCLUSION

The Swedish version of BODY-Q has a good criterion validity and can be recommended in the healthcare for patients with excess skin after massive weight loss and for evaluation of the outcomes from reconstructive surgical procedures.

Physical measurements and patients’ perception of excess skin on arms and thighs before and after bariatric surgery

Background

Bariatric surgery is an effective weight loss method for patients with obesity. One side effect of bariatric surgery is uncomfortable excess skin. Much remains to be learned about physical measurements and patients’ subjective perceptions of it. Here, we investigated the pre- to post-bariatric changes in patients’ perception and physical measurements of the skin on the arms and thighs, in order to find possible subgroups especially affected by post-operative excess skin and to identify predicting factors.

Methods

One hundred forty-seven patients eligible for bariatric surgery completed the Sahlgrenska Excess Skin Questionnaire (SESQ) and underwent measurements of their skin before and 18 months after the procedure.

Results

Although most physical measurements decreased post-operatively, many patients reported increased discomfort. We identified one subgroup particularly prone to report excess skin on the arms post-operatively: women with high discomfort from excess skin on the arms and high body mass index (BMI), pre-operatively. Ptosis of the excess skin seems to be a feasible measurement for predicting post-operative discomfort. For every centimetre of ptosis pre-operatively, patients had 1.37- and 1.31-fold higher odds of achieving a score for post-operative discomfort from excess skin on the upper arms and thighs, respectively, of ≥ 6 (on a 0–10 scale).

Conclusions

We identified a subgroup especially affected by discomforting excess skin on arms and thighs after weight loss. Furthermore, we suggest a pre-operative pro-operative ptosis measuring to predict post-operative discomfort level. The result of this study further increases the knowledge of excess skin and should be useful in further improving patient education.

Level of Evidence: Level III, risk / prognostic study.

The postpartum abdomen: psychology, surgery and quality of life

PURPOSE

The postpartum abdomen presents significant challenges to the surgeon. It is anatomically complex, with often substantial symptomatic divarication of the rectus abdominis, affecting all anterior abdominal wall layers. This may lead to profound functional sequelae, and often, of more importance to patients, a significant physical deformity. The complex interplay of functional/physical symptoms can result in reduced quality of life (QoL) as well as negative body image/self-esteem. Postpartum women may seek abdominoplasty to address the whole scope of these concerns. Whilst techniques have evolved achieving such goals operatively, the impact of such surgery on QoL/mental health has yet to be established.

METHODS

We perform a comprehensive review of potential options of validated patient-reported outcome measures (PROMs) for consideration of use in postpartum women seeking abdominoplasty; in addition to discussing current driving factors for seeking surgery and associated ethics.

RESULTS

Pressure on postpartum women to return their abdominal wall contour to a pre-pregnant state is high. This poses important ethical considerations for surgeons. There are several well-established/validated PROMs used in body contouring in massive weight loss/bariatric population groups, including Body-Q and Body-QoL scales, but none yet specific to postpartum women.

CONCLUSION

PROMs use to enable establishment of the true value of abdominoplasty in postpartum women, not just in terms of functional/physical restoration, but also in terms of delivering a positive impact on patients' mental health and QoL, are important. Further research is needed to determine if those already developed are appropriate or whether a postpartum-specific PROM would be beneficial.

Understanding Uncontrolled Eating after Bariatric Surgery: The Role of Excessive Skin and Body Image Shame

Excess skin and disordered eating behaviors are referred to as some of the major negative consequences of bariatric surgery as well as body image shame. This study sought to explore how discomfort with excessive skin, body image shame, psychological distress, eating-related psychopathology, and negative urgency interact to understand uncontrolled eating among woman submitted to bariatric surgery. A cross-sectional sample of 137 women was evaluated postoperatively through self-report questionnaires assessing discomfort with excess skin, body image shame, eating-related psychopathology, negative urgency, and uncontrolled eating in a hospital center in the north of Portugal. Pearson correlations and Structural Equation Modeling (SEM) were performed. Body image shame mediated the relationship between discomfort with excess skin and eating-related psychopathology. In turn, the relationship between eating-related psychopathology and uncontrolled eating was mediated by negative urgency. This study highlights the impact of excess skin and body image shame on eating behavior post-bariatric-surgery. Considering the proven impact of uncontrolled eating on weight-loss results post-surgery, understanding the mechanisms underlying this problem is highly important. Our findings provide helpful insight for multidisciplinary teams committed to providing care to bariatric patients struggling with body image and eating difficulties.

Excess skin after weight loss following bariatric surgery: focus on the abdomen

BACKGROUND

The majority of postbariatric patients experience major problems from excess skin, with most desiring abdominoplasty.

OBJECTIVES

To present visual assessments and objective measurements of excess abdominal skin; analyze relationships between patient-reported outcomes, objective measurements of excess skin, and visual assessments; and discuss criteria for reconstructive abdominal surgery in public healthcare.

SETTING

An academic hospital in Sweden.

METHODS

This is a secondary analysis of a prospective, longitudinal study that included 200 obese patients undergoing bariatric surgery, with 147 of these patients participating in follow-up 18-months postsurgery. Patients rated their symptoms related to excess skin and quality of life (QoL) according to the Sahlgrenska Excess Skin Questionnaire and EuroQol-5 D before and after bariatric surgery. Abdominal ptosis was measured at different anatomic locations.

RESULTS

Waist circumference and ptosis were significantly reduced at all anatomic locations after weight loss, and abdominal ptosis was significantly larger laterally than at the midline (P < .001). The majority of patients had a ptosis ≥3 cm following bariatric surgery and had significantly more symptoms related to excess skin relative to those reported preoperation (P < .05). Additionally, the number of patients experiencing discomfort from excess skin increased along with increased ptosis size, but the correlation between ptosis size and QoL was low. Reconstructive abdominal surgery was requested by 70% of patients, all having significantly larger ptosis and significantly more symptoms than those not desiring surgery.

CONCLUSION

Criteria for abdominal reconstruction should be based on both patient-reported symptoms and objective measures to ensure more patient-centered care than is possible only using objective measurements.

Exploring the Experiences of Women Who Develop Restrictive Eating Behaviours After Bariatric Surgery

OBJECTIVE

This study aimed to explore the experiences of women who had developed excessively restrictive eating behaviours following bariatric surgery.

METHOD

Five female participants, who were at least nine months post-bariatric surgery and exhibiting restrictive eating behaviours, were recruited from Bariatric Surgery Psychology Services and asked to complete qualitative face-to-face semi-structured interviews. The data was analysed using interpretative phenomenological analysis (IPA).

RESULTS

Three super-ordinate themes emerged: (1) experiences of weight stigma and weight history on self, (2) the impact of loose skin, (3) thoughts about food and disordered eating patterns. These captured the impact of past weight-related experiences-including weight stigma, intense fears of weight gain, negative cognitions about the self, the impact of excess skin, changes in the way the women thought about food and restrictive eating behaviours.

DISCUSSION

This study is one of the first to specifically explore restrictive eating disorders after bariatric surgery using a qualitative approach. The findings of this study may offer helpful aspects for professionals to hold in mind when identifying individuals with problematic restrictive eating behaviours following bariatric surgery. Body contouring surgery, internalised weight bias and weight stigma are explored in relation to the post-bariatric surgery treatment pathway. The current diagnostic criterion for anorexia nervosa are discussed to highlight difficulties in diagnosing this presentation in the post-bariatric surgery population, where people can have BMIs over 25 kg/m2 but are severely restricting energy intake.

Aspects of excess skin in obesity, after weight loss, after body contouring surgery and in a reference population

BACKGROUND

Excess skin is well known after massive weight loss but, there is missing knowledge from various groups.

OBJECTIVES

To describe and compare excess skin in a reference population during obesity, after obesity surgery, and after reconstructive abdominoplasty.

SETTING

University hospital, Sweden.

METHODS

The following 6 groups were included: the reference population, obese adults before obesity surgery, obese adults after obesity surgery, adolescents after obesity surgery, super-obese adults after obesity surgery, and adults after abdominoplasty. All groups filled in the Sahlgrenska Excess Skin Questionnaire (SESQ). Some groups also underwent measurements of ptosis/excess skin on 4 body parts.

RESULTS

All groups scored significantly higher experience of and discomfort from excess skin compared with the reference population. SESQ scores were significantly higher for obese adults (10.5 ± 8.5) and even higher for adults and adolescents (12.3 ± 8.1 versus 14.4 ± 7.7) after obesity surgery compared with the reference population (1.5 ± 3.5). Abdominoplasty resulted in significantly reduced scores (2.9 ± 5.2). Those undergoing obesity surgery and weight loss had significantly less excess skin measured on arms, breasts, and abdomen compared with before surgery, except for the upper arms on the adolescents. Excess skin increased on inner thighs in both age groups after weight loss. Correlations between objectively measured ptosis/excess skin and the patients' experience of and discomfort were .16 to .71, and the highest correlations were found among adolescents.

CONCLUSION

Excess skin is not a problem for the vast majority of the normal population but is linked to obesity and massive weight loss. The SESQ score illustrates major problems related to excess skin both for obese adults and after obesity surgery for adults and for adolescents, who have problems similar to or worse than adults. Abdominoplasty markedly decreases symptoms.

Self-image after bariatric surgery and its relationship to gender, excess skin and health-related quality of life

Introduction: There is limited knowledge about self-image in relation to excess skin after bariatric surgery. The aim of this study was therefore to explore self-image after massive weight loss and its relationship to gender, weight loss, discomfort regarding excess skin and health-related quality of life. Methods: Eighteen months after obesity surgery, 131 patients filled in questionnaires about self-image (Som jag ser mig själv), excess skin (Sahlgrenska Excess Skin Questionnaire, SESQ) and quality of life (EQ-5D and SF-36). In addition, maximal ptosis was measured on their abdomen, arms and thighs. Results: There were no differences in self-image or quality of life between the genders. Participants who scored low discomfort on SESQ had a significantly better overall self-image, in all subscales, compared to those with high discomfort scores (p < .05). They also had a significantly higher quality of life on the EQ-5D VAS (p = .045). Correlations were low, if any, between self-image, excess skin, quality of life and ptosis. There were moderate correlations between the SESQ score and the self-image subscore 'physical well-being', and in self-image and quality-of-life scores. Conclusions: Self-image is lower among those who experience a high degree of discomfort of excess skin after bariatric surgery. Its correlation to weight loss, measured excess skin and quality of life is weak.

Prioritization for Plastic Surgery Procedures Aimed to Improve Quality of Life: Moral Considerations

Background:

Different health conditions are treated in a Plastic Surgery unit, including those cases whose main goal is to enable patients to feel and integrate better within society and therefore improving quality of life, rather then physical functions.

Methods:

We discuss moral principles that can be used as a guide for health professionals to revise and create policies for plastic surgery patients presenting with non–life-threatening conditions.

Results:

A specific anatomical feature is not always an indicator of patient’s well-being and quality of life, and therefore it cannot be used as the sole parameter to identify the worst-off and prioritize the provision of health care. A policy should identify who preoperatively are the worst-off and come to some plausible measure of how much they can be expected to benefit from an operation. Policies that do not track these principles in any reliable way can cause discrimination.

Conclusions:

A patient-centered operating system and patient’s informed preferences might be implemented in the process of prioritizing health. In circumstances when the effectiveness of a specific treatment is unproven, professionals should not make assumptions based on their own values.

Self-reported problems and wishes for plastic surgery after bariatric surgery

In the affluent part of the world, there is an increasing occurrence of obesity with Body Mass Index (BMI) above 40, which has resulted in an increasing number of operations such as gastric bypass (GB). After massive weight loss there will often be a need for subsequent plastic surgical correction, since some of the patients will experience problems due to excess skin. Foreign studies estimate that ∼30% of all bariatric surgery patients will at some point seek plastic surgical correction of excess skin. The aim of this study is to investigate to what extent the GB patients themselves consider plastic surgery for removal of excess skin, and their reasons and motivations for this. The investigation was performed as an anonymous questionnaire handed out to 150 patients at the 1-year standard consultation for GB patients at a private hospital. The questionnaire contained information about demographic data, patient habits, earlier or present comorbidity, physical problems, psychological problems, and cosmetic problems due to excess skin. Also, it contained information about what anatomical area bothered the patient the most. One hundred and thirty-eight patients responded to the questionnaire, and the investigation showed that 89.9% of the patients had a wish for plastic surgery for several different reasons. This patient demand showed to have no correlation to age, gender, smoking habits, or earlier comorbidity.