EUROBESITY

The role of plastic surgery in the treatment of obesity

The growing incidence of obesity is currently a problem that is acknowledged both in Belgium and all around the world. This in turn has led to a growing number of people (no pun intended!) to try and lose weight. While some of these people manage to do so by going on a diet or taking up exercise, the number of bariatric procedures has risen sharply. In the United States, the number increased from 28,8000 operations in 1999 to 63,000 in 2002 and to over 140,000 in 2004. In parallel, there has been a clear-cut upward tendency towards requests for adjustments to body shape. What happens then is that patients are often unpleasantly surprised when they find folds of sagging skin in the wake of a significant loss in weight.

Situation following a loss of weight

Regardless of the way the weight was lost, patients may present with:

  1. a loosening of the abdominal wall and a “sagging apron of skin”;
  2. excess skin round the back, sides and hips;
  3. folds of skin along the side of the chest wall;
  4. ptosis (drooping) of the breasts;
  5. ptosis of the pubic region;
  6. excess sagging skin on the arms;
  7. surplus skin on the thighs.

The abdominal region is the area with the most problems. In addition to folds of skin, there is often a sagging of the abdominal muscles and attendant hernias.

The thoracic region, including the breasts, with both men and women, presents excess skin located mainly on the sides of the ribs. In this area, the skin adheres to the sternum and the spine, causing both vertical and horizontal ptosis.

This needs to be taken into account during any procedure to correct body shape.

Excess skin on the arms extends from the elbows to the underarms and forms a junction with the ribcage.

The thighs do not always change significantly when either putting on weight or taking it off.

Body Mass Index (BMI) gives us an idea of the repercussions that losing weight can have on body shape: a major difference in BMI before and after losing weight produces a number of areas of the body that have changed. There are various ways of losing genetically defined weight and this reduction in size tends not to be uniform. All of the areas that suffer from the results of losing weight have to be approached with care and circumspection.

Liposuction is not sufficient to transform body shape significantly on account of the skin’s inability to retract after being stretched.

Solutions

Surgery aimed at correcting body shape is also of value if there are other associated problems. Apart from the unpleasant aesthetic side of things, people often find it difficult to keep hanging folds of skin clean and dry. Treating intertriginous dermatitis is not straightforward, particularly in hot weather, even with good personal hygiene. It’s not always easy to find the right clothes, either, because the various areas of the body are not always in proportion. Persistent back pain can also be the result of excess abdominal skin.

Surgery designed to remodel body shape has to be “made to measure” in order to correct specific problem areas. Frequently, a number of successive operations are required. To begin with, a circular abdominoplasty (“tummy tuck”) is performed before correcting the abdominal and lumbar regions. Sometimes, an additional mastopexy (“breast lift”) is then carried out, in conjunction or not with an augmentation mammoplasty. A reverse abdominoplasty is a procedure performed less often to correct the thoracic area. An arm lift (also called a brachioplasty) or thigh lift is also frequently associated with this type of surgery. A facelift will correct loose skin on the face and neck. Liposuction can also be performed as a complementary procedure.

Selection of patients

Potential patients who have opted for surgery to correct their body have to be selected and informed with great care. Patients also need to be given realistic prospects as to the results. Perfection is not a realistic aim! The long incisions required leave scarring that is often extensive and patients have to be prepared to accept it. They also need to bear in mind a long recovery period ahead of them.

Major complications may arise and patients have to be able to demonstrate sufficient mental and physical stability to be able to cope.

For some patients, a pre-op psychological consultation is recommended.
The patient’s weight also needs to be stable. If further loss of weight is planned, it is advisable to postpone any plastic surgery. The best results are achieved when the patient has achieved a weight close to his or her ideal body weight. There is also a lower risk of complications when the patient weighs less. The best time to perform plastic surgery is around 6 to 12 months after the patient has achieved a stable weight. If a pregnancy is planned, corrective surgery should also be postponed.

Any chronic medical problems also need to be examined beforehand.

Controlled diabetes and hypertension are not necessarily absolute contraindications. If there is a history of cardiac arrythmia or thrombophlebitis, a full and frank discussion is required before the operation. There is also a need to examine medication, allergies and diet carefully. Making sure the patient is on the right diet is a pre-requisite for the wounds to heal post-operatively. As certain types of bariatric surgery cause malabsorption, the advice of a specialist dietician is recommended.

Smoking is an absolute contraindication! The success of any surgery designed to correct body shape is determined by the survival of large areas of weakened skin. This means it is essential for patients to stop smoking at least 4 weeks before the operation and until all wounds have healed fully.

Procedure

Before the operation
For a patient in good health, a standard blood analysis is sufficient (Co-Fo, coagulation, hepatic and renal function). In general, admission takes place the day before the operation. Pre-operative monitoring by the plastic surgeon is very important and sufficient time needs to be set aside for this purpose. This time will also enable the patient to talk with the surgeon and discuss any concerns he or she may have before the operation goes ahead.
During the operation
Before going into the operating theatre, an intravenous line and possibly an epidural catheter will be inserted. A bladder probe will also be put in place if the procedure is expected to last for more than 3 hours and also in the case of a thigh lift (enabling the wounds to be protected in the early days after the operation). The patient’s safety is of primary concern during the procedure. Sequential compression support stockings are used to prevent deep vein thrombosis. The temperature in the operating theatre is kept sufficiently high, while the position of the patient is scrupulously monitored, using pillows under each pressure point.
After the operation
General speaking, a post-operative stay of at least 2 days is required. An epidural anaesthetic for extensive surgery (such as a circular abdominoplasty) boosts the patient’s comfort for 24 hours. Antalgic medication can also be administered intravenously or intramuscularly.

Whatever the type of procedure, the patient will be got up and made to move about from the first day after the operation. Following an abdominoplasty, the patient will learn to “roll out of bed” without placing too much strain on the wound. After a brachioplasty, the arms have to be kept above the heart. Compression is not indicated with an arm or thigh lift. After an abdominoplasty, a compression dressing is not used initially to ensure that the circulation is not compromised. Checking on wound drainage is a crucial factor in post-op monitoring: drains are removed when secretion is less than 30 ml and in any event after 2 weeks to avoid infection.

Risks and complications

Any procedure designed to correct body shape comes under the heading of elective surgery. Patients must be carefully informed about the risks and complications involved. After learning all the facts, they can then decide whether they are truly prepared to undergo the operation.

The majority of complications are minor and can be treated at post-operative consultations. However, there can be major complications that may lead to the patient being re-admitted, more surgery or an extended period of wound care (longer than 6 months).

Most post-op infections can be resolved by strict wound care and oral antibiotics. Treatment with oral antibiotics is administered routinely until the removal of all drains.

Very often, seromas occur on account of the extensive weakening of the tissue, with fluid collecting under the layers of the skin. When there are drains in place, this fluid will be drained away, but after that it will tend to accumulate. A small build-up of fluid will be resorbed spontaneously, but large seromas are very uncomfortable. Seromas are treated by tapping the collection of fluid, sometimes repeatedly.

Haematomas can occur as the result of a lack of haemostasis, coughing, vomiting or clotting problems. Small haematomas often remain undetected, but when they are extensive, they are accompanied by swelling and sometimes have to be aspirated. In rare cases, the patient may have to be taken back to the operating theatre.

Problems with wounds healing are always possible in view of the fact that all wounds are kept under pressure on purpose. Small areas of dehiscence (wound reopening) will heal if given appropriate care. Larger areas will require secondary closure. It is important to warn patients that a wound may reopen up to 4 weeks after the operation; this is usually caused by making an abrupt movement. Occasionally the circulation can be compromised by closing the wound under traction, which will lead to necrosis of the skin and tissue. These areas usually heal with the right care. It may sometimes be necessary to debride large necrotic areas.

Scars are undeniably associated with surgical procedures. Scars from surgery aimed at correcting body shape are often extensive and cannot always be camouflaged by clothing. Patients need to decide before hand whether they are prepared to tolerate these scars. Scars are initially reddish and puffy, but gradually become paler and even out.

Reduced sensitivity is often reported around scars and areas that have undergone liposuction, but this gradually disappears.

Major complications such as deep vein thrombosis are rare and can usually be prevented by an in-depth discussion of the risk factors involved prior to the operation.

Results from surgery aimed at correcting body shape

In most cases, patients are very satisfied with the results achieved. Surgery to correct body shape meets expectations, despite extensive procedures and long recovery periods. Clothes are usually easier to find, with an average drop of 1 to 2 clothes sizes. Leading a more active life can also be envisaged and the person’s body image is improved.

All of the patient’s efforts to lose weight are finally rewarded by having the corrected body shape they so desperately wanted.

 

News
No current news