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Obesity is a major health crisis with 32% of Americans classified as obese and 5 % as morbidly obese. Weight loss surgery is the most effective long-term treatment for obesity and approximately 200,000 procedures are performed annually. Unfortunately, the surgery does not take care of all of the problems since markedly stretch skin loses its ability to contract completely. Multiple plastic surgery procedures are necessary to improve hygiene and cosmesis after weight is stable at its new low. The most common procedures include a lower body lift, abdominoplasty, thigh lift, breast surgery, upper arm lift (Brachioplasty), blepharoplasty (eyelids), and face/neck lift. A thorough consultation is necessary to determine the staging of the needed surgeries based on patient desires and safety. With most health insurance plans, these are cosmetic surgeries not covered by insurance. Certain procedures combined with reconstructive procedures such as hernia repair may allow for partial coverage but clear communication is necessary to avoid confusion.
The evaluation
Preoperative evaluation of weight, nutritional, physical, and psychiatric status is necessary prior to surgery to maximize safety. These can be evaluated with a history, physical exam, lab tests, and occasionally radiographs. It is important for patients to have proven stability near their goal weight before proceeding with body recontouring, as further significant weight loss or weight gain could negate the effects of otherwise successful plastic surgery. The major weight loss types of surgeries are restrictive, malabsorptive, and a combination of the two. Restrictive procedures reduce the size of the stomach and malabsorptive procedures bypass portions of the gastrointestinal tract to reduce the absorption of what is eaten. Malabsorptive procedures have significant risk for nutritional deficiencies and anemia since these are also absorbed in the gastrointestinal tract. Commonly checked labs are Albumin and Prealbumin (measurement of protein levels in blood), Hemoglobin and Hematocrit (blood counts), coagulation times (clotting ability), electrolytes, and vitamin levels (A, B complex including folate and B12, and C).
The surgical plan can be complicated since many massive weight loss patients have numerous needs of varying severity - facial / neck laxity, eyelid bags, and sagging of breasts, abdomen, buttock, back, chest, thighs, arms, legs, or genitalia. Pairing of procedures to minimize the total number of operations needed while maintaining safety is critical. Each operative plan is tailored to the patient but common combinations include:
- Abdomen and Buttock (Abdominoplasty, Panniculectomy, or Lower Body Lift)
- Breast (Gynecomastia, Mastopexy, or Augmentation) and Arms (Brachioplasty)
- Face and Neck (Rhytidectomy), Eyes (Blepharoplasty), and Chin
- Thighs and Legs
- Hands, Genitalia, and Other
Suspension of layers stronger and deeper than skin is critical in maximizing lift and minimizing scar. Due to the large size of the areas treated and the potential malnutrition, complications such as fluid collections (seromas and hematomas), wound healing problems, infection, scarring, and deep vein thrombosis (DVT/PE) are more common and must be given maximum attention and may require additional prophylactic measures such as prolonged drainage and blood thinner injections at home.
All of the descriptions for the various procedures are condensed from the text of the upcoming textbook written by Dr. Christopher Park and Dr. Malcolm Marks and are copyrighted, "The Artistry of Plastic Surgery: Exploring the Experience” . |
