Aronowitz bariatric plastic surgery


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Aronowitz bariatric plastic surgery

  1. 1. Plastic Surgery After Bariatric Weight Loss… The Final Step in Recovery Joel A. Aronowitz, MD Chief, Division of Plastic Surgery Cedars Sinai Medical Center
  2. 2. How Will I Look After the Weight Is Gone? <ul><li>Skin laxity, redundancy. Failure of skin to shrink back adequately. </li></ul><ul><li>Descent of normal fat pads </li></ul><ul><li>“ Empty Bag” effect </li></ul><ul><li>Changes depend on many factors; individual fat storage pattern, gender pattern, limit of skin elasticity, skin attachments to muscle, age </li></ul>
  3. 3. Principles of Bariatric Changes <ul><li>DEFLATION </li></ul><ul><ul><li>Breasts, abd pannus lose volume and deflate. Minimal shrinkage of skin envelope. </li></ul></ul><ul><li>FIXED ATTACHMENTS </li></ul><ul><ul><li>Fibrous landmarks define fold points, deflated skin drapes and descends over these points of fixation </li></ul></ul>
  4. 4. Bariatric Changes in Body Morphology <ul><li>Adipose or Fat Tissue </li></ul><ul><ul><li>Fibrous supports connecting skin to muscle stretch and tear, leading to… </li></ul></ul><ul><ul><li>Downward migration of anatomic adipose units, such as saddlebags, buttocks </li></ul></ul><ul><li>Muscle </li></ul><ul><ul><li>Anterior abdominal wall muscles and fascia stretch and weaken resulting in distension and hernias </li></ul></ul><ul><li>Skin </li></ul><ul><ul><li>Skin accomodates weight gain by stretching, thinning and loss of elasticity. Final skin redundancy represents a distortion of premorbid pattern </li></ul></ul><ul><ul><li>Excess stretching results in dermal tears, i.e., striae or stretch marks </li></ul></ul>
  5. 5. <ul><li>Non Surgical Treatments </li></ul><ul><ul><li>Fraxel laser useful for stretch marks, face, and minor tightening </li></ul></ul><ul><ul><li>Futile for large skin folds </li></ul></ul><ul><li>Diet/Exercise </li></ul><ul><ul><li>Attention to iron, protein intake </li></ul></ul><ul><ul><li>Muscle firming and cardio </li></ul></ul><ul><ul><li>Little effect on skin laxity </li></ul></ul><ul><li>Work Schedule/ Family Care </li></ul><ul><li>Psychologic prep </li></ul><ul><ul><li>Reward strategy/ depression </li></ul></ul>Patient Preparation for Body Contouring Surgery
  6. 6. Medical Clearance for Body Contouring Surgery <ul><li>Bariatric History </li></ul><ul><ul><li>Stability of weight loss, lifestyle changes </li></ul></ul><ul><li>Medical Clearance </li></ul><ul><ul><li>Preop physical, EKG, blood work </li></ul></ul><ul><ul><li>Management of medical issues such as diabetes, iron defic., anemia, etc. coordinated with bariatric care team and internist </li></ul></ul><ul><li>Physical Exam </li></ul><ul><ul><li>Preop diagnosis of important findings; hernia, mass </li></ul></ul><ul><ul><li>Body contouring strategic plan… </li></ul></ul>
  7. 7. Aronowitz Surgical Worksheet 1 2 3 4 Stage Procedure <ul><li>Assessment of each body area on Aronowitz Bariatric Scale </li></ul><ul><li>Individual plan for each body area </li></ul><ul><li>Prioritize various procedures accommodate patient priorities and surgical realities </li></ul><ul><li>Assemble prioritized procedures into 1-3 staged surgery dates </li></ul>
  8. 8. Patient TC, a 32 yo woman 155 lb weight loss after gastric bypass
  9. 9. Before After <ul><li>Single Stage: Breast lift, abdominoplasty, elevation of Mons pubis, liposuction of love handles </li></ul>
  10. 10. <ul><li>Final result; 11 months post op, note elevation of vulva </li></ul>Before After
  11. 11. <ul><li>Stage 2; Buttockplasty, liposuction of love handles, medial thighplasty </li></ul>Before After
  12. 12. Brest lift (mastopexy) Before After
  13. 13. Nipple elevation with mastopexy Before After
  14. 14. Why the Keyhole Pattern? It is the best method of predictably tailoring the skin envelope
  15. 15. Breast Reduction <ul><li>23 yo GoPo with large pendulous breasts </li></ul>
  16. 16. Case 2: 38 yo woman 210 lb wt loss gastric bypass
  17. 17. <ul><li>Surgical benefits; relief of severely drooping breasts and abdominal folds pannus </li></ul><ul><ul><li>Improves musculoskeletal system </li></ul></ul><ul><ul><li>Improves posture </li></ul></ul><ul><ul><li>Allows increased physical activity level </li></ul></ul><ul><ul><li>Prevents intertriginous rash and infections </li></ul></ul><ul><ul><li>Lowers insulin requirements in some cases </li></ul></ul>Case 2 Before After
  18. 18. Before After Case 2 breast and arm lift
  19. 19. Before After Case 2 breast and arm lift
  20. 20. <ul><li>Breast lift (mastopexy) </li></ul>Case 2 Before After
  21. 21. <ul><li>Brachioplasty and breast lift </li></ul>Case 2
  22. 22. Case 3; 28 year old 90 lb weight loss after gastric bypass and breast reduction
  23. 23. <ul><li>Stage 1; abdominoplasty with belt lipectomy and pubic rejuvenation, breast implants, liposuction and brachioplasty, </li></ul>Case 3 Before After
  24. 24. Case 3 <ul><li>Stage 1; Belt lipectomy, brachioplasty, liposuction </li></ul>Before After
  25. 25. Case 4; 31 year old with abdominal wall laxity after twins
  26. 26. Case 4 <ul><li>Abdominoplasty </li></ul>Before After
  27. 27. <ul><li>Abdominoplasty with repair of rectus diastasis </li></ul>Before After Case 4
  28. 28. <ul><li>Fat injection to buttocks for dimpling, liposuction of thighs, hips and love handles </li></ul>Before After Case 4
  29. 29. GF a 28 yo woman with abd. wall deformity after twins
  30. 30. Patient GF Before After
  31. 31. Patient GF Before After
  32. 32. Alterations in Abdominal Surgical Anatomy After Plastic Surgery <ul><li>Plication of anterior rectus sheath fascia in midline and sometimes laterally </li></ul><ul><li>Plication draws rectus muscles across midline raphe </li></ul>Before plication After plication
  33. 33. Case 5: 35 yo woman with 155 lb wt loss after gastric bypass
  34. 34. Case 5 <ul><li>Stage 1; Belt lipectomy, pubic rejuvenation, breast lift, liposuction thighs, buttock lift </li></ul>Before After
  35. 35. Case 5 Before After
  36. 36. Case 6; 34 yo man with stable 145 lb wt loss on diet alone
  37. 37. Case 6 Surgical Plan <ul><li>Stage 1; abdominoplasty, thighplasty and gynecomastia (breasts) </li></ul><ul><li>Stage 2: completion of belt lipectomy, removal of redundant chest skin and chest tightening </li></ul><ul><li>Stage 3 Touch up scar revisions and liposuction </li></ul>
  38. 38. Case 6 Before After
  39. 39. Before After Case 6
  40. 40. Case 6 Before After Scar at 8 weeks postop
  41. 41. Case 7; 48 yo woman with 115 lb wt loss after gastric bypass
  42. 42. Case 7 <ul><li>Stage 1; abdominoplasty, breast lift, liposuction thighs </li></ul>Before After
  43. 43. Case 7 Before After
  44. 44. Case 9; 26 yo gastric bypass,180 lb loss Before After
  45. 45. Case 9 <ul><li>Stage 1; Abdominoplasty, pubic rejuvenation, thighplasty </li></ul>Before After
  46. 46. Case 9 Before After
  47. 47. Case 9 <ul><li>Stage 1; Abdominoplasty, pubic rejuvenation, medial thighplasty </li></ul>Before After
  48. 48. Case 9 Preop Postop <ul><li>Medial Thighplasty </li></ul>
  49. 49. Case 10; 33 yo woman with 165 lb wt loss after gastric bypass
  50. 50. Case 10 <ul><li>Stage 1; Abdominoplasty, breast lift, brachioplasty </li></ul>Before After
  51. 51. Case 10 <ul><li>Brachioplasty </li></ul>
  52. 52. Are There Health Benefits to Bariatric Plastic Surgery? <ul><li>Removal of abdominal and truncal folds </li></ul><ul><ul><li>Relief of ventral hernia & rectus diastasis </li></ul></ul><ul><ul><li>Relief from chronic rash and intertriginous infections </li></ul></ul><ul><ul><li>Improvement in insulin resistance in some cases </li></ul></ul><ul><ul><li>Improvement in ambulation, exercise freedom </li></ul></ul><ul><li>Relief of severely pendulous breasts </li></ul><ul><ul><li>Improves upper back pain and posture </li></ul></ul><ul><ul><li>Relieves bra strap shoulder grooves </li></ul></ul><ul><ul><li>Allows increased physical activity level </li></ul></ul><ul><ul><li>Prevents intertriginous rash and infections </li></ul></ul>
  53. 53. Case 11; 44 yo man s/p gastric bypass, weight loss > 400 lb.,wheelchair to walker <ul><li>Multiple Stage Plan; Belt Lipectomy with elevation of pubis, flank excision, chest/breast excision, brachioplasty </li></ul>
  54. 54. Stage 2 Stage 1 Stage 3 (free of walker) <ul><li>Procedures; </li></ul><ul><ul><li>Brachioplasty (arms) </li></ul></ul><ul><ul><li>Gynecomastia, breast surgery </li></ul></ul><ul><ul><li>Belt abdominal pannus resection </li></ul></ul><ul><ul><li>Elevation of pubis </li></ul></ul>
  55. 55. <ul><li>Activity improved after 3 stage procedure and continued physical therapy </li></ul>Preop Postop
  56. 56. When Am I Ready for Surgery? (Should I lose more weight?) <ul><li>Weight Stable </li></ul><ul><ul><li>1: Weight goal reached after surgery or diet; Plastic surgery OK. </li></ul></ul><ul><ul><li>2: Weight goal not reached but stable plateau achieved; Plastic surgery OK. </li></ul></ul><ul><ul><li>3: No loss but weight stable; Plastic surgery an option with medical clearance. </li></ul></ul><ul><li>Weight Unstable </li></ul><ul><ul><li>1: If weight unstable after bariatric surgery or diet, best to delay surgery until plateau reached. </li></ul></ul>
  57. 57. Case 12; 48 year old woman
  58. 58. Case 12 <ul><li>Procedures; Mastopexy (breast lift), abdominal belt lipectomy, pubic rejuvenation </li></ul>Before After
  59. 59. Case 12 Before After
  60. 60. Case 12 Before After
  61. 61. Case 12 Before After
  62. 62. The Role of Liposuction <ul><li>Liposuction is excellent technique for contouring fat deposits </li></ul><ul><li>Liposuction removes max. 14 lbs of fat </li></ul><ul><li>Liposuction tightens skin minimally </li></ul><ul><li>Excess, redundant skin must be removed surgically to restore body contour </li></ul>
  63. 63. Case 15; 40 yo nurse, no excess skin, but excess fat of love handles, abdomen, flanks
  64. 64. <ul><li>Liposuction; love handles, abdomen, flanks, total 4,800 cc </li></ul>Before After
  65. 65. Before After <ul><li>Liposuction; love handles, abdomen, flanks, total 4,800 cc </li></ul>
  66. 66. <ul><li>Improvement in body shape by liposuction of love handles and flank rolls </li></ul>Case 15
  67. 67. Case 14 <ul><li>Stage 1; abdominoplasty, breast implants, and brachioplasty </li></ul>Before After
  68. 68. Restoration of the Abdomen after Massive Weight Loss <ul><li>Correction of anterior abdominal wall integrity, repair of hernia and diastasis </li></ul><ul><li>Removal of excess skin </li></ul><ul><li>Restoration of umbilicus </li></ul><ul><li>Elevation and thinning of pubic area </li></ul><ul><li>Thinning of flanks </li></ul>
  69. 69. Case 15; 35 yo with 120 lb loss
  70. 70. Case 15
  71. 71. Case 15
  72. 72. Case 15
  73. 74. <ul><li>Revision of breast reduction with reduction of areola and lift, 6 weeks postop </li></ul>
  74. 75. Patient MP. 55 yo woman with severe implant capsular contracture
  75. 76. Patient MP
  76. 77. Patient 16: 50 yo woman 90 lb weight loss with gastric bypass
  77. 78. Case 16 <ul><li>Breast lift and augmentation with 225 cc silicone gel, Note; removal of xiphoid process </li></ul>
  78. 79. Case 16
  79. 80. Case BS; 36 yo with 50 lb loss
  80. 81. Patient BS
  81. 82. Patient BS
  82. 83. Patient BS
  83. 84. Patient CS; 45 yo gastric bypass, 162 lb wt loss; Brachioplasty
  84. 85. Patient SC Before After
  85. 86. Patient BT Before After
  86. 87. Patient BT Before After
  87. 88. Abdominal Scar Contour Irregularity, Excessive Removal of Tissue with Breast Reduction <ul><li>Breast augmentation, 225 silicone gel </li></ul><ul><li>Repair adipose disruption w/ scar revision </li></ul>Before After
  88. 89. Related Problems <ul><li>Umbilical deformity PO </li></ul><ul><li>Umbilical Hernia </li></ul><ul><li>Ventral hernia </li></ul>
  89. 90. PK; 45 yo with Postoperative Rectus Diastasis/Ventral Hernia <ul><li>At Rest During straining </li></ul>
  90. 91. S/P Repair Midline Diastasis and Scar Revision <ul><li>3 weeks postop </li></ul>8 months postop
  91. 92. Case SA; 60 yo woman with 175 lb wt loss after gastric bypass
  92. 93. Case SA <ul><li>Stage 1; breast lift with implant (250 cc) abdominoplasty with pubic rejuvenation </li></ul><ul><li>Stage 2; thighplasty, buttock lift </li></ul>
  93. 94. Case SA
  94. 95. Case AS Before After
  95. 96. Case AS <ul><li>Procedure; buttockplasty, thighplasty </li></ul>Before After
  96. 97. Questions… <ul><li>When am I ready for plastic surgery? </li></ul><ul><li>What is the recovery period? </li></ul><ul><li>How much pain is involved? </li></ul><ul><li>How much does it cost? </li></ul><ul><li>Does insurance contribute? </li></ul><ul><li>What are the complications? </li></ul><ul><li>Can I speak to someone who has undergone the surgery? </li></ul>