Body mass index is a measurement of body fat based on weight and height. It is calculated using the following equation: Weight in kg/Height (m)2 It is useful when assessing patients before and after massive-weight-loss surgery and can be used to subclassify the degree of obesity. It was described by Keys et al in 1972 where they compared a number of different measures used to assess a patient’s build.1 It has since become a uniformly accepted measurement as a marker of obesity. Body mass index should be recorded for all plastic surgery patients, not only those who have undergone massive weight loss. It will help guide treatments and patient’s suitability for them as well as their risks of certain complications including venous thromboembolism, chest infection, cardiac events, and risks of viral complications.2,3
This patient has a BMI of 29 kg/m2 based on their height and weight, using the calculation: Weight in kg/Height (m)2. The National Institute of Health (NIH) classification for BMI is as follows: • BMI <18.5: Underweight • BMI 18.5–24.9: Normal/healthy weight • BMI 25–29.9: Overweight • BMI 30–34.9: Obese • BMI 35–39.9: Severely obese • BMI > or = 40: Morbidly obese • BMI > or = 50: Super obese Most patients following massive weight loss will reach a plateau to remain with a BMI around 30. Some will be able to go further and achieve a BMI less than this, but most patients tend to remain slightly overweight. The relevance of BMI to body contouring surgery is that operative risks are markedly reduced once patients reduce their BMI to less than 30 or are close to their ideal body weight. They are also more likely to achieve good cosmetic outcomes after surgery. The patient described remains overweight at present but remains in a weight category where plastic surgery would be appropriate. Patients with a BMI above 35 should be encouraged to lose more weight prior to surgery.1,2
3. Hamad GG. The state of the art in bariatric surgery for weight loss in the morbidly obese patient. Clin Plast Surg 2004;31(4):591–600, vi
4. Arterburn D, Gupta A. Comparing the outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass for severe obesity. JAMA 2018;319(3):235–237 The gastric sleeve procedure (see Fig. 122.1, B) has become the most commonly performed procedure to assist in weight loss, although the gastric bypass remains the “gold standard,” as it is more effective at achieving weight loss and putting diabetes into remission. The sleeve gastrectomy is a permanent restrictive procedure that involves creation of a gastric tube by resecting the greater curvature of the stomach, effectively turning it into a sleeve rather than a pouch. It has become more popular than the bypass, as it is more straightforward, less invasive, and incurs a lower complication risk of leakage of bowel contents. Following this procedure, the mean excess weight loss is around 50% at 6 years and there is an associated 70% remission in type 2 diabetes. This is, however, less than with gastric bypass where it is over 90% remission. Gastric banding is usually performed laparoscopically and involves placement of an adjustable band around the top of the stomach. A separate port is connected to the band with silicone tubing and is sited in the subcutaneous tissues. This allows for adjustment of the band when required (see Fig. 122.1, A). The Roux-en-Y gastric bypass is the current benchmark procedure for weight loss. It involves reducing the size of the stomach to create a pouch that is in continuity with the esophagus and intestine. Food consequently passes directly into the small intestine, while the stomach still releases gastric juices that also enter the small intestine and assist with digestion. This procedure means that food intake is restricted, as patients feel full rapidly. The absorption is also affected, but less so than with other malabsorptive techniques (see Fig. 122.1, C). The biliopancreatic diversion (BPD) involves removal of part of the stomach to reduce its size by approximately 75%. The remaining stomach is then directly anastomosed to the lower portion of the small intestine. It is an effective procedure for achieving weight loss of 75 to 80% with good long-term maintenance. However, it may lead to significant nutritional deficiencies, such that patients require lifelong vitamin supplementation and experience foul smelling flatulence and loose stools (see Fig. 122.1, D). The vertical band gastroplasty is a restrictive procedure (also referred to as “stomach stapling”) that typically involves a reduction in stomach size by a combination of staples and a band with mesh wrapped around the stomach opening to help maintain the restriction. It is not very effective and around half of patients are unable to maintain their weight loss with this procedure.1–4
first? The goals of plastic surgery following massive weight loss are to alleviate functional, aesthetic, and psychological impairments associated with skin redundancy and poor contour. Often the functional component is most important, since this can limit the patient’s ability to exercise fully and find clothing to fit well. The order of treatment should always be patient specific, but, in general, the trunk is treated first with a lower body lift, abdominoplasty, or panniculectomy, because an overhanging abdominal pannus and trunk rolls can be quite restrictive in terms of exercising and achieving further weight loss. The breasts and arms would normally be targeted next, followed by the medial thighs, face, and neck.1,2 Most patients will require multiple procedures to correct the skin and soft-tissue excesses following massive weight loss. Some of these can be combined in one operation such as abdomen and breast, or breast and arms as they can be complimentary to one another and help reduce both hospital attendances and overall downtime. They A C Fig. 122.1 Restrictive procedures for bariatric surgery. A, Laparoscopic adjustable gastric band. B, Sleeve gastrectomy. C, Roux-en-Y gastric bypass. D, Biliopancreatic diversion with duodenal switch. Small stomach pouch Larger stomach portion Gastric band Port B Esophagus Gastric sleeve Pylorus Resected stomach Esophagus Proximal pouch of stomach Excluded portion of stomach “Short” intestinal roux limb Duodenum Pylorus 02-03.eps Scaled at 85%. Liver Duodenum Gallbladder Cystic artery Ileum Ascending colon Cecum Appendix Jejunum Stomach Ileum Pancreas Pyloric antrum D can also help make the process more cost-effective for the patient, although this has to be a secondary aim behind optimal clinical decision-making. Patients need to understand the limitations of such surgical intervention and see the process as a work in progress. Many younger patients will not need any intervention to the face or neck at all.
Although this patient has made excellent steps in her weight reduction, it is too early to proceed with body contouring surgery at this stage because she has not maintained a steady weight for sufficient time. Stability for at least 6 months is recommended before proceeding with body contouring surgery. This usually corresponds to at least 12 to 18 months after gastric bypass. The benefits of delaying surgery include a reduction in the risk of perioperative complications, improved aesthetic outcomes, and better wound healing. This delay helps achieve metabolic and nutritional homeostasis. In addition, it provides the patient and surgeon time for discussion and reflection on the best operative plan. Most patients following massive weight loss stabilize at a BMI of 30 to 35 and may benefit from an initial panniculectomy or breast reduction to assist further lifestyle changes such as diet or exercise. Although it may be optimal to wait until patients have a BMI less than 25, it is neither necessary nor realistic to wait until this time, given most patients’ weight stabilizes around BMI 30, and they are unlikely to ever reach the BMI 25 target.1–3
A belt lipectomy has the benefit of addressing multiple areas of trunk skin and soft-tissue excess and accompanying ptosis that are characteristic of the inverted cone physique following massive weight loss. The circumferential excision pattern will address the anterior abdominal panniculus, the lateral abdominal excess, and the lower and mid-back folds. It cannot safely address the upper back fold, which is separately addressed during breast procedures or as an isolated procedure. It also lifts the ptotic tissues from the buttocks, mons pubis, and lateral thighs. This improves the contour of these areas while improving the waistline. The medial thigh will need to be addressed separately with a combination of skin resection and liposuction.1–4
The preoperative markings can be done on the day of surgery, but it is preferable to do them the day before. This enables the surgeon to review photographs of the markings and make any necessary changes. It also increases 1096 Part VII ■ Aesthetic Surgery time efficiency on the day of surgery. The markings will be made with the patient standing for some parts and supine with hips slightly flexed for others (Fig. 122.2). The key aspect when marking is to ensure that sufficient excess will be removed anteriorly and laterally, where the patient can most easily see the result. It is important to ensure the posterior excision is not overdone, because this will lead to tension at the point of closure. In massive-weight-loss patients, the anterior horizontal markings will differ from those for a standard abdominoplasty. The lower incision should be lower to correct mons pubis ptosis. The upper incision may be higher than the abdominoplasty level because of the presence of excess tissue. It will continue away from the midline, oriented horizontally, and will not taper back toward the lower incision. Preoperative markings must be used as a guide and may require adjustment in the operating room to optimally refine the procedure.1–4 Fig. 122.2 Markings for belt lipectomy. A, The midline is marked initially. The horizontal pubic incision is marked below the natural hairline to allow elevation of the mons. The inferior midline of the closure should be level with the pubic symphysis. The pannus is elevated superiorly and medially to allow marking of the lateral extension of the inferior incision to just below the anterior superior iliac spine. B, The superior markings are made anteriorly using the pinch technique to determine the extent of resection. C, The midline of the back is marked with the inferior point at the coccyx. D, The patient is slightly bent at the waist, and the pinch test is used to estimate the superior extent of resection. E and F, The superior and inferior back marks are made to meet the abdominal marks laterally. A B C D E F
When performing a belt lipectomy procedure, scars should be placed to minimize their appearance in most undergarments and swimwear, and this can be achieved by designing them to lie below the pelvic brim. Patients undergoing belt lipectomy will need to be placed in supine, prone, and lateral decubitus positions during the procedure to achieve adequate access. Umbilical lengthening is not required; however, an umbilicoplasty (shortening) is required regardless of the contouring technique used, because the umbilical stalk will have become stretched and elongated during the period of excess weight gain and will not shrink with weight loss. This can help create an aesthetically pleasing umbilicus with some superior hooding and inferior retraction. Liposuction to the lateral thighs should be performed with release of the zones of adherence, in this case to facilitate lateral thigh elevation. The anterior resection is made at the level of the deep fascia or just above it, as per a standard abdominoplasty, but posteriorly the resection is limited to the level of superficial fascia, as this minimizes seroma formation. In addition, the level at which the posterior inferior flap is raised can affect buttock projection. In massive-weight-loss patients, the buttocks are usually under-projected, so it is wise to elevate the posterior flap at the level of the superficial fascia to maximize the soft-tissue volume maintained in this region.1–5
The patient in this scenario most probably needs additional volume for her breasts but is likely to be fairly slim following her weight loss based on her BMI of 26. She is unlikely to have sufficient autologous tissue to augment her breasts and will therefore need prosthetic augmentation to restore adequate volume. Her sternal notch-to-nipple distances are large and should ideally be reduced. This requires skin excision in the form of a mastopexy. The best procedure for this patient is therefore a combined augmentation–mastopexy. This may be as a single- or two-stage procedure. The starting point for discussions will be to see what the patient wishes to achieve in terms of breast shape and volume and whether she would consider a two-stage procedure or only a single stage. She needs to understand that mastopexy or augment alone will not provide her with the optimal result. If performing a two-stage procedure, the breasts can be reshaped in the first instance with a Wise pattern skin excision and coning of the native breast. After 6 to 12 months, implants may be placed in the submuscular/dual plane via an inframammary approach. In contrast, if a single stage is to be performed, then placement of the implant or a temporary sizer should be performed first and the skin reduced accordingly to suit.1–4
her case? The patient in this scenario has a relatively modest weight loss and is now slim. Her breasts are not ptotic but are just underfilled. She should have an augmentation procedure only. When consulting patients like this patient, it is really important to consider whether mastopexy will be required as well as augmentation as otherwise the wrong procedure may be selected, leading to patient dissatisfaction. In cases where there is mild ptosis and good quality soft tissues, augmentation can provide a degree of uplift to the breasts. Conversely if the breasts are more significantly ptotic, the addition of implants may exacerbate the appearance of ptosis.1–3 1098 Part VII ■ Aesthetic Surgery
28 cm with grade III ptosis and a significant lateral soft-tissue excess passing from the breasts toward the axillae. Her BMI is 33. How might her breasts be best managed from a surgical perspective? The patient in this scenario requires additional breast volume and an uplift procedure with skin resection. She remains obese and has excess lateral tissue in the upper trunk which can be used to autoaugment her breasts. Autoaugmentation typically utilizes residual soft-tissue excess from the lateral and inferior breasts as local flaps. A Wise pattern skin approach is used, and this may have additional extension laterally compared with a standard breast reduction pattern depending on tissue excess and volume requirements. Both medial and lateral inferiorly based flaps are de-epithelialized with a central dermal extension including the nipple areola complex. The medial and lateral flaps are then transposed superiorly and fixed to rib periosteum along with the central pedicle to the midline of the breast. Plication of the flaps is then performed to provide maximal internal support. Wounds are closed in a similar way to a standard Wise pattern breast reduction (Fig. 122.3).1–6 Fig. 122.3 Breast reconstruction in massive-weight-loss patients. (From Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques, 2nd ed. St Louis, MO: Quality Medical Publishing, 2011.) Lateral Wise extensions depend on amount of skin roll and/or size of lateral flap desired Central dermal extension suspended to rib periosteum Second rib Pectoralis major fascia Central dermal extension Central dermal extension suspended to rib periosteum Medial flap plicated Lateral flap plicated 5 cm Extent of deepithelialization depends on size of lateral flap used for volume augmentation and need not include entire Wise pattern Lateral flap fixated to rib periosteum and plication initiated Central dermal extension suspended to rib periosteum Medial flap fixated to rib periosteum Fourth rib Dashed lines indicate areas to be plicated Dermis of lateral flap sutured to serratus fascia Central dermal extension suspended to rib periosteum
There are some key principles to consider when addressing the massive-weight-loss patient, particularly with regard to the order of procedures. Before treating the medial thigh, the lateral thigh, waist, and hips should be treated first and this would normally involve a lower body lift. This procedure can target multiple areas including the lower abdomen, flanks, lower back, pubic area, lateral thighs, hips, and buttocks. It may be that treating these areas initially will avoid the need for any subsequent surgical treatment to the medial thigh area. Where treatment is required, the most likely skin excess will be in the horizontal plane (not the vertical); so, a vertical skin pattern resection would be indicated. Liposuction is safe to incorporate into the procedure and actually has become a preferred integral component when using a skin avulsion technique. This involves aggressive liposuction to the area of skin on the medial thigh which is to be excised. Once left with only dermis, the area is incised peripherally and avulsed from the underlying soft tissues. The rationale for this is a reduction in damage to the underlying nerves, blood vessels, and lymphatic channels. Because the skin resection is performed vertically, there is no requirement to lift and support the superficial tissues to Colles’ fascia as part of this procedure. A medial thigh lift is contraindicated in patients with preexisting lymphedema and may actually exacerbate this. Although liposuction is a recognized treatment modality for lymphedema, long-term compression garments would be required following this. The avulsion technique is intended to minimize risk for patients of developing lymphedema.1–5
There are a number of common complications that can occur in patients undergoing body contouring following massive-weight-loss surgery and many of these relate to the wounds themselves. The most common complication of those listed is wound dehiscence (22–30%), and this may be due to excess tension across the wounds, the extent of the wounds, or an underlying nutritional deficiency. Most of the time, this is self-limiting and wounds will heal with prolonged wound care. Other complications include wound infection (1–7%) and skin necrosis (6–10%). These will obviously contribute to wound dehiscence. Patients are also at risk of venous thromboembolism (1%) and this is affected by BMI and procedure type. Prophylaxis is generally recommended with low-molecular-weight heparin 1100 Part VII ■ Aesthetic Surgery shortly after surgery and continued for 7 days, although a more precise individualized risk can be calculated using the Caprini score to guide chemoprophylaxis requirements. Calf-compression garments should be used intraoperatively and thrombo-embolic deterrent hose postoperatively. Hematomas occur in 1 to 5% of cases following body contouring surgery and are most often seen in the early phase. The other common complication is seroma and the range for these varies from 13 to 37% according to procedure and series reviewed. The risk tends to be higher with increased BMI. Drains are used intraoperatively to help minimize seroma development and where they do develop, early aspiration is advocated before capsule formation occurs.1–6