Body-contouring surgery following bariatric surgery: do we need to provide this service?

Abstract

Bariatric surgery is well established as a treatment for obese patients with hypertension and type 2 diabetes. Over one-third of the adults in New Zealand population are overweight and one-fourth are obese.1 Following massive weight loss, patients are often left with hanging and excessive soft tissue. Anecdotally, we know that patients often request removal of this tissue and the most common procedures they seek are abdominoplasty, brachioplasty and medial thigh lift. Given the incidence of obesity and the increasing number of bariatric procedures, it is important to better characterize the number of patients who may benefit from body-contouring surgery and to identify what those benefits are. At our regional service based at Middlemore Hospital, the General Surgery Department has been providing government-funded bariatric surgery since 2007. We have a large cohort of patients who are now over 2 years post-bariatric surgery and from whom we can ask their experience with excess soft tissue and the effect on their lives. We sent questionnaires out to 200 patients who were 2 years post-bariatric surgery and 50 matched controls who had laparoscopic cholecystectomies over the same time period. The response rate was just over 50% for the bariatric surgery patients and only 4% for the control group. Using a Likert scale to assess degrees of concern, we asked about excess abdominal skin, arm skin and thigh skin and how these areas affected the ability to do activities of daily living, social interactions and soft-tissue infections. Of the responses, 97% strongly/agree they had excess skin over the abdomen with 83 and 86% for upper legs and arms, respectively. We also found that 55% had weekly infections from oversized pannus and 21% had yearly infections. The excess skin also caused 42% to agree that abdominal skin limits their ability to exercise, similarly in 61% in those with upper leg and 64% with upper arm excess. The information from this study suggested that there are significant quality-of-life issues related to having this excess soft tissue both psychosocial and physical for patients at a stable weight post-massive weight loss. There is evidence to demonstrate the improvement in quality of life provided by body-contouring surgery following massive weight loss.2, 3 Klassen et al. interviewed 43 patients and found the main concerns precontouring were physical, cosmetic, psychological, sexual and social.4 Overall cosmesis improved but some concerns were raised over scarring. Most reported an improvement in sexual life and a ‘huge difference’ in psychological health. van der Beek et al. also completed quality-of-life questionnaires and showed an improvement,5 as did Araco et al.6 There is additional evidence that weight loss is not only maintained post-body contouring surgery but there is increased weight loss over and above the weight of the tissue removed at the time of surgery.7 The financial cost of body-contouring surgery is significant with a straight forward abdominoplasty requiring 3 h or longer of surgery time with a two-night hospital stay. In our publicly funded institution, the calculated value for this treatment is between NZ$15 000 and $25 000. Post-operative complications may increase this cost. Our impression is that there would be significant demand for body-contouring surgery following bariatric surgery if there was funding available for these procedures. In our department, we currently perform some body-contouring procedures but these are on a case-by-case basis and need to be approved by a group of clinicians who prioritize these ‘restricted procedures’. We believe there is clear evidence for clinicians to demonstrate to the funders of surgery that the benefits from body-contouring surgery are significant enough to warrant allocation of resource to these patients for these procedures.