Massive Weight Loss Patients Research Articles

A Cohort Analysis of Postbariatric Panniculectomy--Current Trends in Surgeon Reimbursement.

The overall number of patients undergoing body contouring procedures after massive weight loss (MWL) has progressively increased over the past decade. The purpose of this study was to evaluate the charges and reimbursements for panniculectomy after MWL at a large academic institution in Massachusetts. A retrospective review was performed and included all identifiable panniculectomy procedures performed at our institution between January 2008 and January 2014. The annual number of patients undergoing panniculectomy, the type of insurance coverage and reimbursement method of each patient, and the amounts billed and reimbursed were evaluated. During our study period, 114 patients underwent a medically necessary panniculectomy as a result of MWL. The average surgeon fee billed was $3496 ± $704 and the average amount reimbursed was $1271 ± $589. Ten cases (8.8%) had no reimbursements, 31 cases (21.8%) reimbursed less than $1000, 66 cases (57.9%) reimbursed between $1000 and $2000, and no cases reimbursed the full amount billed. When evaluated by type of insurance coverage, collection ratios were 37.4% ± 17.4% overall, 41.7% ± 16.4% for private insurance, and 24.0% ± 13.0% for Medicare/Medicaid insurance (P < 0.001). Reimbursements for panniculectomy are remarkably low, and in many instances, absent, despite obtaining previous preauthorization of medical necessity. Although panniculectomy is associated with improvements in quality of life and high levels of patient satisfaction, poor physician reimbursement for this labor intensive procedure may preclude access to appropriate care required by the MWL patient population.

Anh H. Nguyen, MD.

I want to thank my colleague Dr. Anh Nguyen for serving as guest editor of this edition of Seminars in Plastic Surgery and the talented group of authors he has invited to contribute to this issue on cosmetic Asian blepharoplasty and periorbital surgery. Dr. Nguyen is a board-certified plastic surgeon specializing in both reconstructive and cosmetic surgery. He earned his medical degree from the University of Minnesota, Minneapolis, and completed a plastic surgery residency at the University of Southern California Medical Center, Los Angeles, California. Dr. Nguyen continued his training with fellowships in microvascular surgery and craniofacial surgery at the Chang Gung Memorial Hospital, Taipei, Taiwan. He also completed a wound care/burn reconstruction fellowship at Rancho Los Amigos Medical Center, Downey, California. Dr. Nguyen's interests are broad. On the aesthetic side, he is developing a practice that encompasses cosmetic surgery of the face and body, with a particular focus on facial bone contouring and jaw surgery, fat transfer, blepharoplasty, and rhinoplasty, as well as Asian cosmetic surgery. For the reconstructive component, his focus includes complex microsurgical reconstruction of the trauma and oncological defects of the head and neck, breast, and lower extremity; facial reanimation; adult brachial plexus reconstruction; and the body contouring of the massive weight-loss patient. His research concentrates on clinical outcomes and the development of techniques for both reconstruction and aesthetics. He is committed to the education and training of future generations of plastic surgeons at Baylor College of Medicine in Houston, Texas.

Abnormal Vessel Architecture Persists in the Microvasculature of the Massive Weight-Loss Patient

INTRODUCTION: Research demonstrates a link between obesity and increased circulating inflammatory cytokines, leading to changes in the microvasculature. Massive weight loss (MWL) patients often experience delayed wound healing following body contouring procedures, however no studies exist to explore the inflammatory response of MWL on microvasculature. This study hypothesized MWL patients undergoing body-contouring procedures maintain persistently elevated inflammatory markers in the microvasculature that delay wound healing. METHODS: Descriptive data were queried from normal weight and MWL patient charts to assess baseline demographics, medical histories, medications, and smoking status. Superficial inferior epigastric artery (SIEA) vessels were harvested during abdominally-based free flap surgery and abdominal contouring surgery for normal weight and MWL patients, respectively. Vessels were histologically assessed using immunohistochemistry to quantify anti-interleukin-1 (IL-1), IL-6, and TNFα expression. Trichrome staining was performed to assess and compare vessel architecture. Statistical analyses included independent samples two-tailed t-tests and Fisher’s exact test. RESULTS: All patients (n=23) were female. There were no significant differences in patient demographics including preoperative BMI. Quantitative analysis of IL-1, IL-6, and TNFα expression revealed no difference between normal weight and MWL patients (figure 1). Trichrome staining demonstrated abnormal vessel architecture in the MWL group with decreased collagen composition of the tunica adventitia and disorganized smooth muscle in the tunica media (figure 2).Figure 1: Quantification of inflammatory cytokine staining between groups. Results are expressed as percentage of stained versus unstained area per artery cross-section. Normal weight patients are displayed in white while the black bars represent MWL. Bars represent mean with error bars representing standard deviation.Figure 2: Histologic arterial cross-section using Masson Trichrome from normal weight patients (A) and MWL (B) at 10x magnification. Note aberrant vessel architecture in MWL group (B) with minimal tunica adventitia (blue), altered tunica intima, and tunica media organization (dark red) Keratin/Muscle (red); Collagen (blue); Cytoplasm (light red/pink); Nuclei (black).CONCLUSIONS: Despite the return to normal levels of inflammatory markers following MWL, trichrome staining demonstrated irregular composition in the tunica adventitia and tunica media. This suggests vessel pathology that could cause friability and poor delivery of nutrients which could ultimately explain delayed wound healing in the MWL population.

Abdominoplasty in massive weight loss patients with body mass index greater than 35: report of 25 cases

INTRODUCTION: Facial trauma is common, with over 150,000 patients presenting to the emergency room annually in the United States. In patients where imaging is not available, knowing the predictive value of exam findings can allow for improved triage and planning. A prospective clinical study was undertaken to assess the predictive value of physical exam findings in detecting maxillofacial fracture in trauma patients.

Morbidity in combined-procedure associating abdominoplasty and breast surgery: A systematic review

Combined aesthetic procedures are an increasing procedure and demands of the patients. The authors have assembled concrete arguments detailing the risks of combined-surgery associating abdominoplasty and mammoplasty relative to abdominoplasty alone. The purpose of this study was to compare abdominoplasty alone versus abdominoplasty combined with breast surgery in terms of short-term complications, in support of surgical choices. Through application of the PRISMA criteria, we have realized a systematic review of the literature from 1969 to April 2015 in English and French languages by searching in MEDLINE®, PubMed central, Embase and Cochrane Library databases. The levels of evidence for each article were evaluated. Statistical analysis of the results was carried out through association parameters including statistical tests and Odds ratios were calculated for each complication when data was available. We included 32 observational studies that met the inclusion criteria but only four with usable data. We highlighted a combined Odds ratio of respectively 5.35 and 14.71 for major complications in these studies for combined-surgery compared with abdominoplasty alone. The results of this systematic review appears in favor of an increase in major complications related to abdominoplasty combined with breast surgery compared to abdominoplasty alone but the level of evidence of included studies is low or moderate. Prospective cohort comparative studies are necessary to provide strong evidence. However, we recommend to avoid this procedure in massive weight loss patients or patients with thromboembolism history.

The Circumrotational Technique for Mastopexy.

Numerous combinations of pedicle design and incision patterns have been described for mastopexy, but upper pole volume deficiency, suboptimal shape, or recurrent ptosis are still undesired postoperative findings. The challenges of preventing such outcomes are amplified in the massive weight loss (MWL) patient population, where both the extent of morphologic deformation and alterations in tissue characteristics (ie, a materials failure) can be severe. To correct this problem, we propose a technique that combines breast circumference-reduction with maximal glandular rotation and superomedial repositioning: the circumrotational technique. The technique reduces the circumference of the breast base, enhances anterior projection, and defines the lateral breast border by maximal glandular rotation and elevation, reorienting and engaging lax structural elements within the parenchyma. It also recruits ptotic lateral breast tissue into the upper pole, maximizing volume. This technique proposes an initial glandular hyperelevation, upper pole tissue "stacking," and broad peripheral fixation of the breast-to-chest wall to support the breast during the healing period and combat the propensity for recurrence. The circumrotational technique has been mostly used for mastopexy after MWL, but can also be used for typical mastopexies in non-MWL patients with grade 2 or 3 breast ptosis.

The Impact of Protein Nutritional Supplementation for Massive Weight Loss Patients Undergoing Abdominoplasty.

As more patients undergo bariatric surgery to assist with weight loss, the demand for post-bariatric body contouring surgery, to address both functional and aesthetic concerns, is increasing. However, high wound healing complication rates remain a significant problem for these patients. One theory is that chronic malnourishment and hypoproteinemia may contribute significantly to these wound healing complications. The purpose of this study was to determine the effect of pretreatment protein nutritional supplementation on wound healing in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. Our hypothesis was that protein supplementation would decrease wound healing complications. A retrospective review was performed of 23 post-bariatric surgery patients undergoing abdominoplasty who received pretreatment protein nutritional supplementation. This group was compared with a historical control group of 23 post-bariatric surgery patients who underwent abdominoplasty in the period immediately before the implementation of the protein supplementation protocol. Patient demographics and procedural characteristics were similar for the two groups. Forty-six patients were identified who had undergone abdominoplasty, half of whom were prescribed the protein supplementation protocol. Overall wound healing complication rates were significantly lower in the protein-supplemented group (0.0% vs. 21.8%, p = 0.04). There was no significant difference between the protein supplementation and historical control groups in regards to total complication rate. Pretreatment protein supplementation is a simple intervention that can significantly decrease wound healing complications in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. LEVEL OF EVIDENCE 4: Therapeutic.

Removal of excess skin after massive weight loss: challenges and solutions

Removal of excess skin after massive weight loss: challenges and solutions Salvatore Giordano Department of Plastic and General Surgery, Turku University Hospital, Turku, Finland Abstract: The advent of bariatric surgery has led to a subspecialty in plastic surgery for skin and fat contouring which remain after massive weight loss. The author discusses the preoperative assessment, surgical treatment plan, postoperative management, possible complications, and benefits of postbariatric surgery. Preoperative planning includes medical history and patient assessment. Surgical procedures for brachioplasty, upper back lift, breast reshaping, abdominoplasty, panniculectomy, lower back lift, and thigh lift are discussed. Indications, postoperative complications, and benefits are also discussed. The best candidates for postbariatric plastic surgery are those who have achieved weight loss stability with a BMI of 32 or less and who have adequate nutrition in order to heal the surgical excisions. Abdominal and truncal deformity are the most common presenting complaints in massive weight loss patients, and the procedure of choice to address this region is a body lift. Postoperative care focuses on patient safety, prioritizing in deep venous thrombosis (DVT) prophylaxis and seroma prevention. Postbariatric body contouring aims to correct the deformity due to the excess of skin after massive weight loss and to restore a sense of normalcy. Keywords: morbid obesity, bariatric surgery, weight loss, massive weight loss, body contouring, panniculectomy

Extended Fasciocutaneous Flaps for Autologous Augmentation Mastopexy With Upper Body Lift After Massive Weight Loss

Common upper body findings after massive weight loss (MWL) include breast ptosis, projection loss, flattening, inframammary fold descent, and back rolls. Although implants address volume loss, manifestations of circumferential excess (ie, back rolls) are ignored. We review our experience with extended lateral fasciocutaneous flaps incorporating circumferential excess tissue, typically removed in upper body lifts (UBLs), for autologous augmentation mastopexy. We reviewed all cases of simultaneous autoaugmentation mastopexy and UBL, using extended lateral chest wall fasciocutaneous flaps, performed after MWL. Donor sites were designed with scars residing within the bra line (UBL) or midaxillary line [modified UBL (mUBL)]. We analyzed demographics, clinical indications, and complications. Between 2007 and 2013, 7 patients underwent 13 extended fasciocutaneous flap reconstructions for autoaugmentation mastopexy, combined with UBL or mUBL. All patients underwent procedures with flaps taken from the back or from the midaxillary line. Mean initial body mass index (BMI) was 50.1 kg/m2 with a preoperative, post-MWL BMI of 28.5 kg/m2, weight loss of 58 kg, and BMI decrease of 21.6 kg/m2. Among 6 patients who underwent bariatric surgery, the average interval between gastric bypass and autoaugmentation mastopexy was 41 months. Five patients underwent these procedures for aesthetic reasons, whereas 2 patients underwent breast reconstruction. Follow-up averaged 18 months. Complications occurred in 3 patients, with only 1 requiring reoperation. Massive weight loss patients frequently present with breast volume loss and ptotic upper body soft tissue excess. Simultaneous mastopexy augmentation can be safely and reliably performed using extended fasciocutaneous flaps to autologously may be placed in aesthetically acceptable locations. Patients undergoing mUBLs with midaxillary line donor scars may conceal them with arms at their sides. Patients choosing back donor scars may conceal them within the bra line while having greater volumes available for augmentation. As is true with all flaps, one should assess distal tip perfusion before final inset, especially when using a flap extending to the midline back.

Post-Bariatric Body Contouring.

The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical. The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them. This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed. Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them. There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.

Commentary on: Thiamine deficiency: a cause of profound hypotension and hypothermia after plastic surgery.

In this interesting case report, the authors recount a case of a massive weight loss patient undergoing panniculectomy who had profound hypotension and hypothermia following the operation.1 The patient had a complicated intensive care unit course with significant interventions to keep her circulatory system functioning. The symptoms resolved with administration of thiamine. This case underscores the importance of an awareness of nutritional deficiencies in the massive weight loss patient. In this case, the …

Aesthetic refinements in body contouring in the massive weight loss patient: Part 2. Arms.

The literature has witnessed an evolution in brachioplasty technique since the procedure was introduced by Thorek in 1930. Aesthetic refinements in brachioplasty have been increasingly described in the literature, and this has paralleled the rise in the massive weight loss population. The aim of this review is to share the plastic surgery experience with this challenging body region and present different approaches to achieve the best results for a broad spectrum of patients. A literature review studying brachioplasty was performed through PubMed. Throughout the literature there has been debate about scar placement, scar length, application of liposuction, drain placement, and optimization of outcomes, and differences of opinion have been compared. There is no definitive best method of brachioplasty, as evidenced by multiple classification systems which present algorithms for management depending on presentation. Not only does approach differ depending on degree of presentation, but there are also different approaches depending on author for similar manifestations. Approaches vary through incision length, incision placement, and use of liposuction. Outcomes studies similarly reveal lack of consensus. This literature review has elucidated multiple approaches to brachioplasty, and the pearls and pitfalls described may all be incorporated to produce excellent outcomes and patient satisfaction in an individualized approach.

Four-Step Medial Thighplasty

The medial thigh remains a troublesome region for body contouring in both the aging patient and in the massive weight loss patient. Liposuction-assisted medial thighplasty is the next step in the series of medial thigh contouring refinements to improve complications and outcomes. Forty-five patients are presented who underwent medial thigh contouring with liposuction-assisted medial thighplasty. After anatomical analysis of the medial thigh, noting skin and fat redundancy, patients were selected for either an upper/inner medial thighplasty or an extended medial thighplasty. Operative markings, liposuction, and the excisional technique are presented with intraoperative video footage. Twenty-nine patients (64 percent) presented with aging thigh lipodystrophy, whereas 16 patients (36 percent) were massive weight loss lipodystrophy patients. The patients' ages ranged from 30 to 67 years, with 0.5 month to 9.5 years of follow-up. Liposuction evacuation volumes ranged from 175 to 1950 ml per thigh. Ten patients had minor wound breakdown, which healed with conservative wound care. Liposuction-assisted medial thighplasty is a safe, efficient, and reproducible procedure that should follow a four-step algorithm: (1) L-shaped anterior markings, (2) superwet infiltration, (3) circumferential combined superficial ultrasound-assisted/suction-assisted liposuction, and (4) predesigned and patterned skin excision and layered closure. It simplifies the markings and resection, and the procedure preserves the lymphatics and nerves, minimizes blood loss, and maintains the saphenous vein system to prevent skin loss and wound breakdown. It produces reliable and predictable results, with optimal outcomes. This technique offers another refinement in the evolution of medial thigh contouring.

The Correlation of Matrix Metalloproteinase 9–to-Albumin Ratio in Wound Fluid with Postsurgical Complications after Body Contouring

The authors' earlier retrospective report of surgical complications after abdominal contouring surgery provided evidence that post-bariatric surgery patients are at increased risk of developing wound complications compared with a normal population. This prospective pilot study was designed as a comparative analysis of both surgical and wound healing characteristics between massive weight loss and normal patients who present for abdominal contouring surgery. Excisional wounds were created and polytetrafluoroethylene tubing was inserted during the preoperative period for later harvesting in patients undergoing abdominal contouring following Roux-en-Y gastric bypass for weight loss (n = 16) or abdominoplasty (n = 17). Wound fluids were sequentially collected from drains and subjected to matrix metalloproteinase (MMP) analysis. Standard postsurgical complications were documented. Surgical complications were more common in weight loss patients (47 percent) than in control patients (25 percent). MMP analyses showed that MMP-9 levels remained significantly elevated at postoperative day 4 in patients who subsequently experienced complications in either the weight loss group (p = 0.02) or the control group (p = 0.03). Other parameters showed no significant differences between massive weight loss patients and controls. Although many markers were examined, the ratio of MMP-9 to albumin was the only predictor of postsurgical complications in any group. This lends further support to growing evidence that MMP-9 may be a useful biomarker of postsurgical complications. This pilot work showed no causal factors that explain the higher rates of postsurgical complications in the post-bariatric surgery patient population. Risk, II.

Prevention of Seroma and Other Post-Operative Complications Using Continuous Negative Pressure Drain Devices Following Panniculectomy in Massive-Weight Loss Patients

Prevention of Seroma and Other Post-Operative Complications Using Continuous Negative Pressure Drain Devices Following Panniculectomy in Massive-Weight Loss Patients

Photographic standards for the massive weight loss patient.

Photographic standards issued by the Plastic Surgery Educational Foundation ensure accurate comparisons between preoperative and postoperative imaging. These standards, however, do not properly display the circumferential body ptosis seen in massive weight loss (MWL) patients. Photographic standardization for massive weight loss patients is needed for patient consultation, surgical planning, and accurate analysis and comparison of postoperative results. A 10-year review of the photographic standards used for MWL patients at the University of California Davis Medical Center were reviewed and compared to current photographic standards in plastic surgery and clinical photo documentation seen in the literature for body contouring after MWL. Evaluation of arm position in obscuring the evaluation of circumferential ptosis in the upper and lower body was performed. Current photographic standards in plastic surgery do not capture the circumferential ptosis often seen in MWL patients, and there are no consistent modifications or standards recommended for MWL patients. Arm position was noted to affect shadowing and obstruction as well as distortion of circumferential excess. During the first 5 years reviewed, initial consultations included 8 images captured at 45-degree increments with the arms abducted to 90 degrees to document the circumferential excess from shoulders to the knees (Total Body, Fig. 1). They also included 8 images focused on the lower body (Fig. 2) and 8 images focused on the upper body. This required a total of 24 images captured per consultation. During the latter 5 years reviewed, the 8 Total Body images continued to be captured whereas the 16 images focusing on the upper and lower body have been discarded and replaced with 10 images (Fig. 3), captured from shoulders to knees at 45-degree increments with arms positioned behind the back (5) and in the lap (5) for a total of 18 images captured per consultation. Currently there are no photographic standards for MWL patients that accurately capture their circumferential ptosis. All arm positions affect the evaluation of the circumferential excess to some degree, thus any choice of arm position represents a compromise between visibility and distortion of anatomy. Having considered these issues, we recommend the use of 360-degree clinical photo documentation obtained at 45-degree increments with arms abducted to 90 degrees to capture the total body. We have discarded focused upper and lower body images as these are visible in the Total Body images, thus decreasing patient fatigue and discomfort from excessive pictures. As techniques in post-bariatric body contouring have improved, we now routinely compare our results to non-post-bariatric body contouring patients and thus have added more standard arm positioning to facilitate these comparisons.

Gluteal reshaping in the massive weight loss patient.

Gluteal reshaping in the massive weight loss patient.

A preliminary report on the development of a validated tool for measuring psychosocial outcomes for massive weight loss patients

To validate the newly developed patient report outcome measure (PROM): the Post Bariatric Outcome Tool (PBOT). The tool is designed and developed for massive weight loss patients seeking body contouring procedures. The PBOT was piloted with three cohorts: massive weight loss patients seeking body contouring; massive weight loss patients who have had body contouring; and healthy, non-obese subjects as controls matched for age and gender. Each cohort completed two PROMS at week one, and then for a second time at week three. The PROMS used were the new Post Bariatric Outcome Tool (PBOT) and the Derriford Appearance Scale 24 (DAS24). The PBOT was shown to be reliable both in terms of its internal consistency and test-retest reliability. Comparison to the DAS24 demonstrated the PBOT to be valid. However, the cohorts were small and responsiveness was not tested. This needs to be tested in further larger validation studies, ideally, with comparison to functional scales such as the SF-36 or other validated massive weight loss body contouring PROMs; such as the Body Q.

The Effect of Massive Weight Loss Status, Amount of Weight Loss, and Method of Weight Loss on Body Contouring Outcomes

The impact of massive weight loss (MWL) on body contouring procedures and outcomes has not been firmly established in the literature. The authors investigate the correlations between MWL status, the method of achieving MWL, and the amount of weight lost with wound-healing complications after body contouring procedures. The charts of 450 patients (124 of whom had undergone MWL) who underwent body contouring procedures including abdominoplasty, brachioplasty, thighplasty, breast mastopexy/reduction, lower bodylift, bodylift, buttock lift, and liposuction were reviewed. MWL patients were classified as having achieved weight loss through diet and exercise, gastric banding or sleeving, or gastric bypass. Postoperative complication data were collected, including cases of infection, delayed wound healing, seroma, hematoma, dehiscence, and overall wound problems. Odds ratios (OR) were estimated using 4 multivariate logistic regression models. MWL status was a significant predictor of wound problems (OR, 2.69; P < .001). Patients with 50 to 100 lbs of weight loss did not have a significantly increased risk of wound problems (OR, 1.93; P = .085), while patients with over 100 lbs of weight loss did (OR, 3.98; P < .001). Gastric bypass (OR, 3.01; P = <.001) had a higher risk correlation than did diet and exercise (OR, 2.72, P = .023) or restrictive bariatric surgery (OR, 2.31; P = .038) as a weight loss method. Patients who lost over 100 lbs demonstrated increased risk of complications if they had gastric bypass or restrictive procedures. MWL was a significant risk factor for wound complications in the body contouring population. Method and amount of weight loss were also significant factors in predicting complications.

An improved dual approach to post bariatric contouring - Staged liposuction and modified medial thigh lift: A case series.

Objective:Following massive weight loss (MWL) medial contouring of the thigh is frequently requested to improve appearance and function. Thigh lifting can be associated with significant complications. We present a case series of post bariatric patients undergoing thigh lift using staged the liposuction, a modified T incision and a buried de-epithelialised dermal flap.Materials and Methods:From January to December 2012, 21 consecutive patients underwent a modified medial thigh lift. A retrospective review of the case notes was performed to assess complications that occurred.Results:There were no major post-operative complications in terms of reoperation, hematoma, thromboembolism and no seromas. Seven patients, all of which were smokers had minor superficial wound healing complications. Aesthetic outcomes were satisfactory for all patients at a minimum follow-up of 6 months.Conclusions:The modified ‘T’ incision with staged liposuction is described. We have found the technique to be useful for a variety of different thighs. It is a reproducible method for contouring the medial thigh in MWL patients. In this series, our overall complications were low, and no seromas occurred.