Presentation obesity


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Presentation obesity

  1. 1. Principles of bariatric surgery Unit vi Dr anand (pg)  Under gudience of Prof. m.ramesh krishana
  2. 2. BARIATRIC SURGERY (SURGERY FOR MORBID OBESITY)  (Bariatric =Baros: heaviness, and pressure.) INTRODUCTION Bariatric surgery is currently only modality that provides a significant sustained loss of weight for the patient with morbid obesity.& with related co-morbidities
  3. 3. Goals  The goal of bariatric surgery is to improve health in morbidly obese patients by achieving long-term, durable weight loss.  It involves reducing caloric intake and/or absorption of calories from food, and may modify eating behavior by promoting slow ingestion of small boluses of food.  Restrictive operations restrict the amount of food intake by reducing the quantity of food that can be consumed at one time, which results in a reduction in caloric intake.  Malabsorptive procedures limit the absorption of nutrients and calories from ingested food by bypassing the duodenum and predetermined lengths of small intestine.
  4. 4. BARIATRIC EVALUATION  In 1969, Mason and Ito performed the first gastric bypass, in which a loop of jejunum was connected to a transverse proximal gastric pouch.  Bile reflux esophagitis was severe postoperatively,  In 1977 Griffin to developed the Roux-en-Y modification of the gastric bypass  In 1980, Mason described vertical banded gastroplasty (VBG), a restrictive procedure in which stapling was used to create a proximal gastric pouch of the upper lesser curvature of the stomach,  with placement of a restrictive band to form its outlet to the rest of the stomach
  5. 5.  In Italy, late 1970, Scopinaro had developed and popularized the biliopancreatic diversion (BPD) procedure along with its modification to include a duodenal switch (DS), has been the only major malabsorptive operation to enjoy long-term success.  The laparoscopic approach to bariatric surgery became available in the 1990  In 1994 Belachew and colleagues performed the first laparoscopic adjustable gastric banding (LAGB) operation .  Wittgrove and Clark performed the first laparoscopic Roux-en-Y gastric bypass (LRYGB) the same year.
  6. 6.  In 2001 LAGB was approved for use in the United States by the U.S. Food and Drug Administration.
  7. 7. OBESITY EPIDEMIOLOGY  Obesity now considered as a "Killer lifestyle" disease is an important cause of preventable death worldwide.  According to the World Health Organization (WHO), 1.2 billion people worldwide are officially classified as overweight.  This is probably the most sedentary generation of people in the history of the world. In the Indian scenario, even with the growing awareness about health and fitness, more than 3 percent (3 crores ) of the Indian population is obese
  8. 8. ETIOLOGY An excess of caloric intake in relation to caloric expenditure results in deposition of fat or adipose tissue Obesity is multifactorial  Genetic  Environmental factors  Diet  Culture  Other factors
  9. 9.  Genetics plays an important role in the development of obesity.  Although the children of parents of normal weight have a 10% chance of becoming obese,  The children of two obese parents have an 80 to 90% chance of developing obesity by adulthood.  The weight of adopted children correlates strongly with the weight of their birth parents. Furthermore, concordance rates for obesity in monozygotic twins are double those in dizygotic twins.2
  10. 10. Differential Diagnosis and Related Diagnoses  A few endocrine diseases are associated with obesity, including hypothyroidism,  Cushing's disease, and adult-onset diabetes mellitus.  However, patients who seek medical or surgical treatment for morbid obesity rarely have an endocrine etiology of their obesity.  syndrome X.( combination of central obesity, glucose intolerance, dyslipidemia, and hypertension)
  11. 11.  CLASSIFICATION  The degrees of obesity are defined by body mass index,  BMI (calculated as weight in kilograms divided by height in meters squared).
  12. 12. Classification BMI Range (kg/m2)  Normal weight 20–25  Overweight 26–29  Obese 30–34  Severely obese 35–49  Superobese ≥50
  13. 13. COMORBIDITIES,  Degenerative joint disease  Low back pain, hypertension,  Obstructive sleep apnea,  GERD)  Cholelithiasis,  Type 2 diabetes, hyperlipidemia,  Hypercholesterolemia, asthma, hypoventilation syndrome of obesity, 5
  14. 14.  Fatal cardiac arrhythmias, right-sided heart failure,  Migraine headaches  deep vein thrombosis,  Fungal skin rashes, skin abscesses,  Stress urinary incontinence, infertility, dysmenorrhea,  Depression,  Abdominal wall hernias,  Increased incidence cancers such as those of the uterus, breast, colon, and prostate.
  15. 15. Life expectancy  Obesity has a profound effect on overall health and life expectancy  largely secondary to weight-related comorbidities.  It is estimated that a man who is severely obese at age 21 will live 12 years less than a nonobese individual,  and a severely obese woman will live 9 years less.  This is largely due to the fact that severely obese men often are dead of comorbid medical conditions, especially cardiac arrhythmias and coronary artery disease, by age 50
  16. 16. Treatment and mangement  Non surgical  Surgical
  17. 17. NON SURGICAL LIFE STYLE MODIFICATIONS  DIET  a deficit of 500 kcal per day, resulting in a weekly deficit of 3500 kcal, translates to the loss of one pound of fat a week.  EXCERISE  Behavior modification  Pharamacotherapy
  18. 18. PHARAMCOTHERAPY  Pharmacotherapy is a second tier therapy usually used in heavier patients (BMI >27)  when lifestyle changes alone have failed.  It is employed alone or in combination with lifestyle changes
  19. 19. Sibutramine & orlistat are c (FDA)–approved drugs for weight loss treatment.  Orlistat is a potent and selective inhibitor of gastric and pancreatic lipases that reduces lipid intestinal absorption,  sibutramine is a noradrenaline and 5- hydroxytryptamine reuptake inhibitor that works as an appetite suppressant.  Despite their different MOA they effectively produce weight loss of 6 to 10% of initial body weight at 1 year,
  22. 22. Indications  Patients that have a BMI of 35 kg/m 2 or more with comorbidity, or  those with a BMI of 40 kg/m 2 or greater regardless of comorbidity,  Candidates must have attempted weight loss in the past by medically supervised diet regimens, exercise, or medications.  patients aged 18 to 60 years.  Adolescent patients with morbid obesity may be considered for bariatric surgery under select circumstances.
  23. 23. CONTRA-INDICATIONS:  Patients who are unable to undergo generalAnesthesia because of cardiac, pulmonary, or hepatic disease,  Patients with ongoing substance abuse, unstable psychiatric illness,  inadequate ability to understand the consequences of surgery are also considered to be poor surgical candidates.  those who are unwilling or unable to comply with apostoperative lifestyle changes, diet, supplementation, or follow-up may not undergo these procedures.
  24. 24. PRE OPERATIVES EVALUTIONS INCLUDES  Patient selection  Pre operative prepartion  anesthesiology assessment
  25. 25. Pateint selection Multidisciplinary team evaluation  Physician  Specific nutritional counseling and education is required based on the operation to be performed Psychologic assessment  Treatment of the depression is felt to improve postoperative outcomes.
  26. 26. Preoperative Preparation  comorbidities and other medical problems  Screening for coronary artery disease in patients >50 years of age  sleep apnea in severely obese patients, when all routinely undergo sleep studies  GERD taking medication, a preoperative screening upper endoscopy to rule out Barrett's esophagus and intrinsic lesions of the stomach or duodenum is recommended
  27. 27.  patients who are taking anticoagulants for prosthetic cardiac valves or  recent venous thromboembolism, anticoagulation therapy must be managed  H/O venous thromboembolism or who are felt to have multiple risk factors for postoperative venous thromboembolism are potential candidates for preoperative placement of a temporary inferior vena cava filter. Such filters are placed the day before surgery & removed 3 to 6 weeks postoperatively
  28. 28.  Ultrasound of the abdomen in patients planning to undergo LRYGB who have an intact gallbladder to rule out the presence of gallstones.  Evaluation of thyroid function is recommended preoperatively, because hypothyroidism is not uncommon in this patient population.  Serum chemical analysis, liver function tests, and the usual screening blood tests are performed.  Blood tests to determine baseline nutritional parameters commonly reveal abnormally low iron and vitamin D levels
  29. 29. Anesthesiology Issues  Cardiopulmonary evaluation to identify any underlying pathology that requires preoperative treatment to decrease perioperative morbidity from cardiopulmonary complications  Two major difficulties the anesthesiologist faces when administering a general anesthetic to a severely obese patient are vascular access and airway management
  30. 30.  Alterations in the metabolism of specific anesthetic drugs in the severely obese include a larger volume of distribution
  31. 31. Restrictive  Laparoscopic adjustable gastric banding (LAGB)  Sleeve gastrectomy (SG)  Vertical banded gastroplasty (VBG)a Malabsorptive  Biliopancreatic diversion (BPD)  Jejunoileal bypass (JIB) Combined restrictive and malabsorptive  Roux-en-Y gastric bypass (RYGB)  BPD with duodenal switch (DS)
  32. 32. Indications for Conversion from Laparoscopic to Open Surgery 1. Failure to establish an adequate pneumoperitoneum 2. Hemodynamic adverse reaction to pneumoperitoneum 3. Intra-abdominal adhesions precluding safe access or presenting excessive difficulty in accessing abdomen 4. Hepatomegaly such that retraction is not feasible or organ visualization is obscured even with retraction 5. Intraoperative complications such as hemorrhage that are best managed with an open approach 6. Exceedingly thick body wall precluding adequate trocar access or manipulation
  33. 33. LAPARASCOPIC Adjustable Gastric banding:  Silicon band with adjustable diameter placed at the entry of stomach (cardia) Two types of bands have been used  The original Lap-Band Adjustable Gastric Banding System, ( Allergan) most frequently.  The Swedish adjustible gastric band, Realize Adjustable Gastric Band by Ethicon
  34. 34. Adjustable gastric banding • Sep/1993= first laparoscopic AGB (Belachew M) • Types of Adjustable Bands: 1-Bioenterics = Lap- Band=Silicone 2-Swedish adjustable gastric band
  35. 35.  Mechanism of Action  Adjustable gastric banding involves the minimally invasive (laparoscopic) or open- approach  placement of a silicone band around the proximal stomach to restrict the amount of solid food that can be ingested at one time.  the adjustable nature of the band allows the amount of restriction to be increased or decreased, depending upon the patient's weight loss
  36. 36. Technique The patient is placed in the steep reverse Trendelenburg position. Six laparoscopic ports are placed. A 5-mm liver retractor is used to elevate the left hepatic lobe. A 15-mL gastric calibration balloon is used to identify the locationbegins with division of the peritoneum at the angle of His, then division of the gastrohepatic ligament in its avascular area (the pars flaccida) to expose the base of the right crus of the diaphragm Once the band is passed around the proximal stomach, it is locked into its ring configuration through its own self-locking mechanism. Once the band is securely locked in place, the buckle portion of the band is located on the lesser curvature of the stomach
  37. 37. Patient Selection and Preparation  Most LAGB procedures are done on an outpatient basis.  the relative risk of the procedure is lower than that of most other bariatric operations,  which makes this procedure more suitable to offer to older, more medically ill, or higher-risk patient populations. Poor candidates for LAGB  patients who have had previous upper gastric surgery, such as a Nissen fundoplication, due to the potential tissue compromise in taking
  38. 38.  Pateint who , are immobile, are unable to exercise, nibblers on high-calorie sweets, and expect to be able to continue their dietary habits
  39. 39. Postoperative Care  Patients are given clear liquids a few hours after the procedure.  A Gastrografin swallow is obtained on the first postoperative day to confirm band position and patency.  Patients can generally be discharged 1 to 2 days after surgery with a liquid diet for 4 weeks.  At that time, a gradual transition to a regular diet is started.  Band adjustment may be performed with fluoroscopic guidance initially at 10 to 12 weeks.  Patients are assessed monthly for weight loss and tolerance of oral intake.  Band adjustments are made accordingly every 4 to 6 weeks during the first year following laparoscopic adjustable gastric banding.
  40. 40. Advantages  Laparoscopic adjustable gastric banding is a relatively simple procedure that takes less operative time than the more complex procedures such as laparoscopic RYGB or laparoscopic biliopancreatic diversion.  The mortality rate is low (0.06%), as are conversion rates (0 to 4%).  No staple lines or anastomoses are required. Recovery is rapid and hospital stay is short.  The adjustable nature of the laparoscopic band allows the degree of restriction to be optimized for the patient's weight loss.
  41. 41. Disadvantages  With this procedure, there is a potential for port site complications and the need for frequent postoperative visits for band adjustment.  Some patients (5 to 10%) experience band slipping or gastric prolapse, which usually requires reoperation.  Other potential problems include band erosion, port-related complications, gastroesophageal reflux, alterations in esophageal motility, and esophageal dilatation.  Should inadequate weight loss occur, revision to Roux-en-Y gastric bypass is feasible, but
  42. 42. EARLY COMPLICATIONS OF ADJUSTABLE GASTRIC BANDING..  Wound infection  pneumonia  Injury of stomach or oesophagus  Bleeding
  43. 43. Late complications  Food intolerance or noncompliance  Band slippage(stomach prolapse)  Pouch dilation  Band erosion into stomach  Port complications  Re operation rate  Oesophageal dilatation  Failure to lose weight  Leakage of ballon or tubing
  44. 44. Open Roux-en-Y Gastric Bypass  Mechanism of Action  RYGB is both a gastric restrictive procedure and a mildly malabsorptive procedure.  A small gastric pouch restricts food intake, while the Roux-en-Y configuration provides malabsorption of calories and nutrients.  Mason described the optimal parameters for restriction necessary for adequate weight loss, including a gastrojejunostomy of 1.2 cm or less in diameter and a gastric pouch of 15 to 30 mL.
  45. 45.  The abdomen is entered through a midline incision and is thoroughly explored. The gallbladder is inspected and palpated for gallstones  Three superimposed staple lines are applied to the stomach so as to create a proximal pouch of 15 to 30 mL
  46. 46.  The ligament of Treitz is identified and a point 15 to 45 cm distally is identified.  The jejunum is divided with a linear stapling device.  The mesentery is divided between clamps and a side-to-side jejunojejunostomy is created with a linear stapler to create a 45- to 75-cm Roux limb for a standard gastric bypass,  a 150-cm limb for a long-limb modification in the superobese. With a lengthened Roux limb, there is a greater degree of malabsorption for improvement of weight loss.
  47. 47.  The Roux limb is brought through the transverse mesocolon.  A 1-cm gastrojejunal anastomosis is created between the gastric pouch and the jejunum, using a circular stapler or a hand-sewn, two-layer technique.  The hand-sewn anastomosis is created over a 30F dilator
  48. 48. Postoperative Care  If a nasogastric tube is left in place at the time of surgery, it is removed within 24 hours.  Gastrografin swallow is generally obtained on the second or third postoperative day and liquids are started thereafter.  Patients are generally discharged 2 to 6 days after surgery.
  49. 49. Advantages  TheRYGB is more effective than vertical banded gastroplasty in terms of weight loss.  In a more recent study in which sweet-eaters were assigned to gastric bypass and non–sweet-eaters were assigned to vertical banded gastroplasty,
  50. 50.  RYGB has been demonstrated not only to prevent the progression of non–insulin- dependent diabetes mellitus, but also to reduce the mortality from diabetes mellitus, primarily due to a reduction in deaths from cardiovascular disease.  Durable control of diabetes mellitus is achieved following gastric bypass, along with or resolution of other comorbidities such as hypertension, sleep apnea, and cardiopulmonary failure.
  51. 51. Disadvantages  Dumping syndrome  including distal gastric distention and internal hernia.
  52. 52.  Laparoscopic Roux-En-Y Gastric Bypass (LRGB)  The laparoscopic approach to gastric bypass (LRYGB) was first described in 1994  The major feature of the operation is the creation of a proximal gastric pouch of small size (often <20 mL) that is totally separated from the stomach  A Roux limb of proximal jejunum is brought up and anastomosed to the pouch.  The pathway of that limb can be anterior to the colon and stomach, posterior to both, or posterior to the colon and anterior to the stomach.  The length of the biliopancreatic limb from the ligament of Treitz to the distal enteroenterostomy is from 20 to 50 cm, and the length of the Roux limb is 75 to 150 cm.
  53. 53. • First Laparoscopic gastric bypass was in 1993 by Wittgrove, Clark, a nd Tremblay.
  54. 54.  Patient Selection and Preparation  LRYGB is an appropriate operation to consider for most patients eligible for bariatric surgery.  Relative contraindications to LRYGB include previous gastric surgery, previous antireflux surgery, severe iron deficiency anemia,  Distal gastric or duodenal lesions that require ongoing future surveillance, and Barrett's esophagus with severe dysplasia  Preoperative flexible upper endoscopy for all patients contemplating RYGB is advocated by some to rule out lesions of the stomach or duodenum
  55. 55. Postoperative Care and Follow-Up  Patients undergoing LRYGB usually are hospitalized for 2 to 3 days  We routinely perform a postoperative oral contrast study on the 1st POD to rule out a leak  an early asymptomatic leak or to edema or stenosis of the enteroenterostomy or to any other obstructive pattern of the proximal bowel  follow-up visits are usually for 3 mthen onths, 6 months, and 1 year after surgery, annually after that.  testing for postoperative nutritional deficiencies.
  56. 56.  Outcomes  Patients undergoing LRYGB usually lose between 60 and 80% of excess body weight during the first year after surgery  Postoperative nutritional complications after LRYGB include :  iron deficiency anemia in 20%,  vitamin B12 deficiency in 15%,  and vitamin D deficiency in at least 15%, which usually is present preoperatively.
  57. 57. EARLY COMPLICATIONS of Roux-en –y gastric bypass  Anastomic leak (1-3%)  Pulmonary embolism,DVT  Wound infection(mc open apprroach)  GI hemorrhage,bleeding  Respiratory insuffciency,pneumonia  Acute distension of distal stomach
  58. 58. LATE COMPLICATIONS  Stomal stenosis mc  Bowel obstruction  Internal hernia  Cholelithiasis  Micro nutrient deficiencies  Marginal ulcer  Staple line distruption  Ventral hernia(MC open approach)
  59. 59.  Life long oral or IM vit B-12 supplememtation  Iron,folate,calcium specific nutrient deficency
  60. 60.  Biliopancreatic diversion (BPD) was first described by,Scopinaro and colleagues in ItalY,  It involves resection of the distal half to two thirds of the stomach and creation of an alimentary tract of the most distal 200 cm of ileum, which is anastomosed to the stomach  The biliopancreatic limb is anastomosed to the alimentary tract either 75 or 100 cm proximal to the ileocecal valve, depending on the protein content of the patient's diet
  61. 61. Mechanism of Action  A 50- to 100-cm common absorptive alimentary channel is created proximal to the ileocecal valve; digestion and absorption are limited to this segment of bowel.
  62. 62. Indications  This procedure is primarily indicated for the superobese or for those who have failed restrictive bariatric procedures.  Less commonly, some surgeons perform BPD as a primary operation in the non-superobese.
  63. 63. Contraindications  Patients with anemia, hypocalcemia, and osteoporosis, and  those who are not motivated to comply with stringent postoperative supplementation regimens may not be appropriate for this procedure.
  64. 64. AdvantaGES  the malabsorptive component of the BPD allows for excellent results in terms of weight loss.  This operation may be more effective than gastric bypass or restrictive surgery in patients with severe morbid obesity (e.g., BMI greater than 70 kg/m 2 ),
  65. 65. Disadvantages  The BPD is technically a more complex procedure than the restrictive procedures. Protein malnutrition with anemia, hypoalbuminemia, edema, and alopecia are among the serious adverse sequelae of this operation.  Severe vitamin deficiencies may occur, leading to osteoporosis and night-blindness.  Treatment requires prolonged hyperalimentation and supplementation
  66. 66. COMPLICATIONS biliopancreatic diversion with duodenal switch  Fat malabsorption leads to diarrhea foul smelling gas  Nutrional deficiencies  Malabsorption of fat soluble vitamins (ADE&K)  Iron deficiency  Protein-energy malnutrition
  67. 67.  First introduced by Ganger Micheal in 2002  It is the first step when you do Biliopancreatic diversion with Duodenal switch procedure (BPD+DS)  It is temporary step to reduce weight before the permanent procedure which is BPD+DS (when BPD+DS is difficult to be done duo to excessive fat or huge Lt. liver lobe)
  68. 68. Patient Selection and Preparation  Patients undergoing SG two groups.  One group is high-risk superobese patients considering eventually undergoing the second procedure to complete the DS operation.  The other group is patients who have a BMI of <50 kg/m2 and have decided that they prefer the SG operation.
  69. 69. TECHNIQUE  The surgeon begins the gastric resection by dividing the vessels along the greater curvature of the stomach using the Harmonic scalpel.  Division is begun 2 to 3 cm proximal to the pylorus and continued to the angle of His
  70. 70. Outcome  SG results in excellent short-term weight loss  Depending on body size, weight loss is in the range of 45–50% of excess weight for patients with a BMI of >60 kg/m2,  For patients with a BMI of 35 to 50 kg/m2 with a 32F pouch size, excess weight loss at 3 years was recently reported as being 60%
  71. 71. Vertical Gastrectomy Advantages  Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.  Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).  No dumping syndrome because the pylorus is preserved.  Minimizes the chance of an ulcer occurring.  By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.  Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).  Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2).  Appealing option for people with existing anemia, Crohn’s disease and numerous other conditions that make them too high risk for bypass
  72. 72.  As with any surgery, there can be complications. Complications can include:  DVT (blood clot in leg)  Pulmonary Embolus (blood clot to lung)  Pneumonia  Splenectomy  Gastric leak and fistula.  Postoperative bleeding  Small bowel obstruction  Death
  73. 73.  Big…big size single meal eater  Non-sweet eater  Non-compliance patients  motivated patients  Does not loss significant by dieting history
  74. 74. Advantages  60% a mean excess weight loss  Less than 10% early morbidity rate  Less than 1% perioperative mortality disadvantages  Nearly 80% failure rate (long term follow-up  Poor weight loss maintenance  15% to 20% reoperation rate duo to stomal outlet stenosis or severe reflux
  75. 75. Special Issues Relating to the Bariatric Patient Bariatric Procedures in the Female Patient: Pregnancy and Gynecologic Issues  Hormonal levels in female patients are related to body weight.  Obesity alters the levels of estrogen and progesterone available for normal ovulation, which results in abnormal ovulation patterns, amenorrhea, and difficulty conceiving.  the increased chances of gestational diabetes and hypertension make the pregnancy high risk. Macrosomia is increased.  RYGB had a lower incidence of
  76. 76. Bariatric Surgery in Morbidly Obese Adolescents  Bariatric surgery in morbidly obese adolescents is controversial.  Surgery may be indicated in this population because of the dismal failure of the conservative methods of weight control,  adolescent obesity, and the many disabling and deadly obesity-related comorbidities of adulthood.  Bariatric surgery should be seriously considered after conservative methods have failed.
  77. 77. IN ELDERLY  Most clinical trials exclude older patients, and little is known about the benefits of diets or drugs that induce weight loss in these age groups.  Mechanical complications of obesity, such as osteoarthritis and static respiratory complications, seem to improve with weight loss, even at higher ages.  Recent studies suggest that bariatric surgery, previously considered contraindicated in obese patients above age 60, can be safely performed even in patients above age 70, with
  78. 78. Type 2 Diabetes  surgeons performing RYGB that patients who had undergone the operation showed improvement or near resolution of type 2 diabetes well before they had achieved maximum weight loss.
  79. 79. Metabolic Syndrome  Metabolic syndrome is characterized by central obesity, glucose intolerance, dyslipidemia, and hypertension.  Metabolic syndrome is a common finding in patients with severe obesity, occurring in 52% of individuals in one report.  All the associated metabolic problems of metabolic syndrome respond to surgical therapy to produce weight loss.  Diabetes and pre-diabetes (fasting plasma glucose of 100–124 mg/dL) are effectively treated by both RYGB and LAGB
  80. 80. Resolution of Other Comorbid Medical Problems with Bariatric surgery:  Obstructive sleep apnea Musculoskeletal problems,  degenerative joint disease and  low back pain,
  81. 81. Post operative follow up:  High protein,low-fat diet,supplement multivitamins,iron,and calcium.  Ursodil minimize the risks of development gallstones  Nutritional and metabolic blood tests need Performed on frequent basis.3 months, 6months,12 months after surgery,then annually
  82. 82. Post bariatric surgery body contouring  Massive weight loss associated with flabby skin,abdominal skin overhang and pendulous breast  Redundant roll of tissue associate with hygiene problems
  83. 83. TREATMENT  Conventional surgery lipoplasty  Combination of 2 procedures  Abdominoplasty , buttock lift, lower body lift  Thigh lift ,upper arm lift. Facelift, breast reduction.mastopexy. COMPLICATIONS  Hematomas.  seromas,  skin slough  ,fat necrosis & DVT
  84. 84. Thank you