A 48-year-old man who lost 200 kg through diet and exercise underwent a lower body lift. During the 4-hour, 2-surgeon procedure, he required repositioning 3 times and 6 drains. Post-operatively he developed hemorrhages requiring exploration. He was discharged after 8 days requiring weekly drainage of seromas. The document discusses nutritional deficiencies common after bariatric surgery that can impact wound healing for body contouring procedures. It notes diet and exercise patients have higher complication rates than those who had bariatric surgery. Careful patient evaluation and counseling is important due to the risks and limitations of massive weight loss body contouring.

2. Body Contouring and massive
weight loss in the NHS

3. 48yo man MWL 200-100kgs
diet and exercise only

4. Presents to outpatients requesting information
on Body Contouring Surgery

5. Highly motivated professional with no
significant past medical history

6. • May 2009 following PCT
approval and adequate
counseling underwent
– Lower body lift
• 9.9kgs of subcutaneous
tissue excised
• 4 hour 2 surgeon approach
• Patient re-positioned 3
times
• X6 drains
• Intra-operatively required
6units of PC
• Otherwise unremarkable

7. Post-op
• Day 1:
– BP 80/40 HR 110, 1 drain >1L over 2 hours
– Immediate exploration and evacuation of 3L haematoma
with no bleeding source identified
• Day 1:
– 12 hours after first exploration
– BP undetectable, ABG Hb 4, aggressive resuscitation and
re-explored
– Minor bleeds cauterised but nil identifiable source
– Evacuation of 2.2L haematoma
• Short stay in ICU but following 32 units of PC
discharged day 8

8. Outpatients
• Weekly drainage of seroma collections
• Extremely happy!!!
• Can’t wait to get the next stage of his BC
performed

9. The Obesity Epidemic
• Derived from the Latin word obesus – “to
devour”
• Obesity is growing at an alarming rate in both
children and adults in Westernized countries

10. International Union of Nutritional Sciences. The global
challenge of obesity and the International Obesity Task
Force:2002

13. The Obesity Epidemic
• According to recent data, the number of annual deaths attributed to obesity (in the United States) is
estimated to be 112,000. International Union of Nutritional Sciences. The global challenge of obesity and
the International Obesity Task Force: Tables. Available at http://www.iuns.org/features/obesity/
tabfig.htm#Table%201. Accessed on September 6, 2005.
• Although this number is lower than the earlier estimate of 300,000 deaths, Ogden, C. L., Flegal, K. M.,
Carroll, M. D., and Johnson, C. L. Prevalence and trends in overweight among U.S. children and
adolescents. J.A.M.A. 288: 1728, 2002.
• Morbidities associated with obesity, including:
– diabetes,
– heart disease,
– some cancers,
– and arthritis,
• Reduce a patient’s quality of life and contribute to escalating medical costs.

14. Prevalence of obesity, diabetes, and obesity related health risk
factors. Mokdad, A. H., Ford, E., Bowman, B. A., et al. J.A.M.A. 289: 76, 2001
• A weight gain of 11 to 18 pounds increases a person’s
risk of developing type 2 diabetes to twice that of
individuals who have not gained weight
• >80% of people with diabetes are overweight or obese
• Incidence of heart disease is increased in persons who
are overweight
• High blood pressure is twice as common in adults who
are obese than in those who are at a healthy weight
• For every 2-pound increase in weight, the risk of
developing arthritis is increased by 9 to 13%

15. Bariatric surgery: A systematic review and meta-
analysis. Buchwald, H., Avidor, Y., Braunnald, E., et al. J.A.M.A. 292: 1724,
2004
• Comprehensive review and meta-analysis
analyzed 136 bariatric surgery reports.
• This study reviewed 22,094 patients with a
mean age of 39 years (range, 16 to 64 years)
• Average body mass index of 46.9 (range, 32.3
to 68.8).
• The group was 72.6% female and 27.4% male.

16. Bariatric surgery: A systematic review and meta-
analysis. Buchwald, H., Avidor, Y., Braunnald, E., et al. J.A.M.A. 292: 1724,
2004
• The authors concluded that co-morbidities were
improved by bariatric surgery
– Lipid disorders improved in 70% of patients.
– Diabetes improved in 76.8% of patients.
– Hypertension improved in 78.5% of patients.
– Obstructive sleep apnea improved in 85.7% of
patients.
• The positive physical improvements that often
accompany weight loss, as well as the increase in
self-esteem, can equate to an improved quality of
life for these patient

17. • American Society for Bariatric Surgery, its
member surgeons performed:
– 28,800 weight loss operations in 1999
– 63,000 weight-loss operationsin 2002,
– 140,000 weight-loss operations in 2004
• Mayo Foundation for Medical Education and Research. Gastric
bypass: Is this weight-loss surgery for you?

18. • American Society of Plastic Surgeons, nearly
56,000 body contouring procedures were
performed for massive weight loss patients in
2004

19. • The increased safety and effectiveness of
bariatric surgery give plastic surgeons
additional opportunities to refine body
contouring

20. Bariatric Surgery Procedures
• Bariatric surgery is
currently the only therapy
effective at achieving
weight loss with significant
improvement or resolution
of co-morbidities
– Buchwald, H., Avidor, Y., Braunnald, E.,
et al. Bariatric surgery: A systematic
review and meta-analysis. J.A.M.A.
292: 1724, 200

21. Bariatric Surgery Procedures
• Bariatric procedures are
typically classified as:
– Purely restrictive
• Gastric adjustable banding
• Vertical-banded gastroplasty
• Gastric balloons
– Restrictive >malabsorptive
• Short-limb/Roux-en-Y gastric
bypass
– Malabsorptive> restrictive
• Biliopancreatic diversion
• Very long limb Roux-en-Y
gastric bypass
– Purely malabsorptive
• Jejunoileal bypass
• Jejunocolonic bypass

23. Implications of Weight Loss Method in Body Contouring
Outcomes
Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D.
Plast. Reconstr. Surg. 123: 373, 2009
• 499 patients (511 cases) were entered into a
prospective registry.
• Diet and exercise patients were matched to
bariatric patients based on identical procedures
performed
• All patients with a weight loss of greater than 50
lb were included
• 477 cases (93.3 percent) had bariatric procedures
• 29 patients representing 34 cases (6.7 percent)
lost weight exclusively through diet and exercise

24. Implications of Weight Loss Method in Body Contouring
Outcomes
Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D.
Plast. Reconstr. Surg. 123: 373, 2009

25. • Conclusion, that diet and exercise had:
– higher absolute complication rates,
– significantly higher infection rates (p = 0.03).
– When matched to 191 bariatric patients based on
procedures performed, had a higher complication rate
that did not reach significance (odds ratio, 1.5; p
=0.28)
– One-to-one matching resulted in 34 procedure-
matched pairs with non-significant trends toward:
• better nutrition and albumin
• more complications

26. • Conclusion, that diet and exercise had:
– higher absolute complication rates,
– significantly higher infection rates (p = 0.03).
– When matched to 191 bariatric patients based on
procedures performed, had a higher complication rate
that did not reach significance (odds ratio, 1.5; p
=0.28)
– One-to-one matching resulted in 34 procedure-
matched pairs with non-significant trends toward:
• better nutrition and albumin
• more complications

27. Potential Impacts of Nutritional Deficiency of Postbariatric Patients on Body
Contouring Surgery
SiamakAgha-Mohammadi, M.B., B.Chir., Ph.D. Dennis J. Hurwitz, M.D.
Plast. Reconstr. Surg. 122: 1901, 2008
• Protein-Calorie Malnutrition
– 25% of weight loss surgery patients are at risk of
developing protein-calorie malnutrition
– Protein deficiency impairs wound healing because
protein is needed for:
• fibroblast proliferation
• angiogenesis
• collagen production
• oedema adversely affects perfusion of the healing tissues
– severe protein-calorie malnutrition associated with
immunosuppression which in turn correlates clinically
with increased wound complication rates

28. Vitamin B6, Vitamin B12, and Folate
Deficiencies
• Folate deficiency has an incidence of 9-35% after
bypass operations.
• vitamin B6 deficiency is approximately 17.6 %
• vitamin B12 deficiency ranges from 3.6-37% at 1
year after Roux-en-Y gastric bypass
• Folate and vitamin B12 are required for the
formation of S-adenosylmethionine, which is
critical for stabilization of DNA and many proteins
– Thus, deficiencies of these vitamins can potentially
contribute to poor cellular proliferation and repair in
the post-bariatric body contouring

29. Thiamine
• Deficiencies of thiamine likely to be
subclinical.
• Thiamine plays an essential role in the
metabolism of carbohydrates and branched-
chain amino acids
– thus may have an important role in the healing
process.

30. Vitamin C Deficiency
• Incidence of vitamin C deficiency in Roux- en-Y
gastric bypass patients is:
– 34.6% at the 1 Year
– 35.4% - and 2-year
• Plays an important role in wound healing by:
– Increasing collagen synthesis
– Angiogenesis
– associated with capillary leakage caused by decreased
collagen production and susceptibility to wound
infections

31. Vitamin A Deficiency
• up to 69% of post-bariatric patients 4 years
after surgery
• Vitamin A is an essential factor in the healing
patient, as it functions as an:
– Immunostimulant,
– Enhancing inflammation-driven wound healing

32. Vitamin E
• Vitamin E plays an important role in
supporting monocyte/macrophage-mediated
responses
• Also excess supplementation can inhibit
collagen synthesis and decrease tensile
strength of wounds because vitamin E has
anti-inflammatory properties similar to
steroids .

33. Iron Deficiency
• 30-50% with all types of bariatric surgery
• May present with microcytic anemia
• Post-bariatric body contouring patients can lose a
significant amount of blood during surgical
procedures, it is important that the patient’s
haemoglobin and haematocrit are optimized in
the preoperative setting.
• Severe iron deficiency can impair collagen
production and increase the risk of opportunistic
infections

34. Zinc Deficiency
• Deficiency is demonstrated in 36% of post-bariatric
patients despite vitamin supplementation
• Zinc-deficient subjects are at risk of decreased :
– fibroblast proliferation
– collagen synthesis,
• leading to decreased wound strength and delayed epithelization
• Has role in supporting the both the humeral and
cellular immune system.
– resulting in an increased susceptibility to wound infection
and the possibility of delayed healing

35. Charing Cross Experience
• Currently bariatric surgery is funded by PCT
with hundreds of procedures performed
yearly
• Body contouring surgery not yet funded by
PCT
• Therefore, scores of eligible patients who will
miss out on BC surgery

36. When to operate?
• Minimum 12 months after gastric
banding/bypass surgery
• 3 months of stable body weight
• BMI <30
• When possible stage the body contouring
procedures.
– Atleast 3 months between BC procedures
procedures

37. Implications of Weight Loss Method in Body Contouring
Outcomes
Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D.
Plast. Reconstr. Surg. 123: 373, 2009
• 499 patients (511 cases) were entered into a
prospective registry.
• Diet and exercise patients were matched to
bariatric patients based on identical procedures
performed
• All patients with a weight loss of greater than 50
lb were included
• 477 cases (93.3 percent) had bariatric procedures
• 29 patients representing 34 cases (6.7 percent)
lost weight exclusively through diet and exercise

38. Implications of Weight Loss Method in Body Contouring
Outcomes
Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D.
Plast. Reconstr. Surg. 123: 373, 2009

39. • Conclusion, that diet and exercise had:
– higher absolute complication rates,
– significantly higher infection rates (p = 0.03).
– One-to-one matching resulted in 34 procedure-
matched pairs with non-significant trends toward:
• better nutrition and albumin
• more complications

40. • Conclusion, that diet and exercise had:
– higher absolute complication rates,
– significantly higher infection rates (p = 0.03).
– One-to-one matching resulted in 34 procedure-
matched pairs with non-significant trends toward:
• better nutrition and albumin
• more complications

41. Potential Impacts of Nutritional Deficiency of Postbariatric Patients on Body
Contouring Surgery
SiamakAgha-Mohammadi, M.B., B.Chir., Ph.D. Dennis J. Hurwitz, M.D.
Plast. Reconstr. Surg. 122: 1901, 2008
• Protein-Calorie Malnutrition
– 25% of weight loss surgery patients are at risk of
developing protein-calorie malnutrition
– Protein deficiency impairs wound healing because
protein is needed for:
• fibroblast proliferation
• angiogenesis
• collagen production
• oedema adversely affects perfusion of the healing tissues
• Iron deficiency anaemia in 30-50% with all types
of bariatric surgery

42. Potential Impacts of Nutritional Deficiency of Postbariatric Patients on Body
Contouring Surgery
SiamakAgha-Mohammadi, M.B., B.Chir., Ph.D. Dennis J. Hurwitz, M.D.
Plast. Reconstr. Surg. 122: 1901, 2008
• Folate deficiency has an incidence of 9-35% after
bypass operations.
• Vitamin B6 deficiency is approximately 17.6 %
• Vitamin B12 deficiency ranges from 3.6-37% at 1
year after Roux-en-Y gastric bypass
• Incidence of vitamin C deficiency in Roux- en-Y
gastric bypass patients is 34.6% at the 1 Year
• Vitamin A deficiency up to 69% of post-bariatric
patients 4 years after surgery

44. Key Points for Review with the Massive Weight Loss
Patient
• Length of body contouring procedures
• Need for multiple/staged procedures to achieve
optimal result
– Ability to go back and revise as needed
• Increased risk in smokers
• Scars:
– Placement
– Migration
– Contracture
– Asymmetry

45. Key Points for Review with the Massive Weight
Loss Patient
• Recurrent skin laxity
• Potential for sensory loss, especially in the arms
• Inability to close the wound
• Risk of deep vein thrombosis/pulmonary embolism
• Potential for:
– Dehiscences
– Seromas
– Lymphocele/lymphedema
• Importance of weight maintenance
• Possibility of:
– Sexual dysfunction
– women Vulvar distortion

46. Preoperative Evaluation
• Body habitus/fat
deposition patterns
• Morphology of skin
redundancy
• Degree of skin deflation
• Body mass index at
presentation
• Quality of skin envelope
• Scar placement

47. Deflation
-Tissue deflation is often,
but not always, present in
the massive weight loss
patient.
-Patients with a similar
body mass index and total
weight loss can present as:
-deflated,
-mildly deflated, or
-non- deflated
(minimum loss of fat)

50. EVALUATING THE UPPER TRUNK
• Evaluation of the upper trunk should include a
thorough analysis of the:
– breast and chest
– upper back.

53. EVALUATING THE THIGHS/LEGS
• Determine the degree
of deflation and excess
skin and the location
and amount of excess
fat.

54. EVALUATING THE FACE
• The face of the massive
weight loss patient ages
prematurely
• These patients tend to
lose more volume in the
mid-face, and their skin
is more lax and less
elastic
• Marked excess of laxity
in the neck region

56. Surgical goals in lower body
procedures
• Flattening the abdomen
• Recreating the umbilicus
• Elevating the mons
• Creating a waist in female patients
• Excision or liposuction of lower back rolls
• Defining the buttocks
• Lifting the outer/anterior thighs
• Improving the inner thighs

57. Abdominoplasty (tummy tuck)
• Removes extra skin and fat from the navel to
the pubic area
• Tightens muscles in the abdomen
• Liposuction may be done during BC surgery

58. Dr Ted Lockwood
High Lateral Tension suture
2001
• Classic approach improves contour by pulling
inferiorly on the central abdomen, thereby
creating the highest tension along the central
incision,
– HLT pulls obliquely from each of the incision's 2
lateral arms, thereby placing the highest tension
laterally.

68. Panniculectomy
• Removes a large apron of skin and fat that
hangs from the abdomen below the belly
button
• No tightening of muscles, liposuction, or
moving the belly button is done

75. Mons Reduction
• Rejuvenate the pubic area of the massive
weight loss patient

76. Surgical goals in upper body
procedures
• To reshape/augment breast parenchyma to
restore projection and fullness
• To achieve appropriate nipple-areola complex
position and size
• To recreate/reposition the inframammary fold
• To reduce the skin envelope
• To eliminate prominent axillary skin rolls
• To elimination mid- and upper-back rolls

77. Breast Reshaping
• Asymmetrical volume
loss in the massive
weight loss breast,
• More of a deflated and
flat appearance of the
breast.
• Skin laxity is very
apparent

78. Age: 37
Procedure:
Mastopexy
Weight Lost: 75kgs after Lap-BAND
14 months post-BC

79. Age: 38
Procedure: mastopexy augmentation (implants)
Weight Lost: 60kgs after gastric bypass
24 months post-BC

80. Breast in Male Massive Weight Loss
Patients
• Body mass index: before weight loss and
current
• Degree of nipple-areola complex ptosis
• Amount of breast projection
• Amount of hypertrophy
• Amount of excessive skin
• Loss of inframammary fold definition

82. 28-year-old man
Procedure: mastopexy and liposuction of the chest
Weight loss: 30kgs

83. Arm lift (brachioplasty)
• Removes excess skin that
hangs loosely from upper
arms
• Liposuction may be needed
before or during surgery to
remove excess fat in upper
arms

84. Age: 58
Procedure: brachioplasty
Lost: 45kgs after gastric bypass surgery
5 months post-BC Before

85. Age: 45
Procedures: Brachioplasty, axilloplasty, and mastopexy
Weight Lost: 60kgs after Roux-en-Y gastric bypass
4 months post-BC Before

87. Arm lift (brachioplasty)

88. Rhytidectomy (facelift) in the massive weight loss
patient requires a multiplaner technique to adequately
address both volume deficiency and skin laxity