Body Contouring Surgery After Massive Weight Loss
Condition: Weight Loss
MeSH terms: Body Weight; Weight Loss
Study type: Observational [Patient Registry]

Summary: 
      Body contouring (BC) surgery after major weight loss (MWL) requires extensive and multiple
      procedures. Yet, there are inconsistent data regarding the outcome after BC procedures. The
      aim of this study is to investigate the outcome from patients who elect to have BC procedures
      after MWL treated at a single metropolitan tertiary referral center.
    

Detailed description: 
      Background The obesity epidemic worldwide continues to worsen, with rates in Europe and North
      America estimated at about 20-30% of the adult population.(Vico et al., 2010) It is defined
      as a body mass index (BMI) above 30, and morbid obesity as a BMI above 40kgm-2.(Strauch et
      al., 2006; Vico et al., 2010) As a consequence, there is an explosive growth of
      obesity-associated comorbidities, associated with high healthcare costs.(Reiffel et al.,
      2013) One of the few consistent means of achieving a significant weight-loss in morbidly
      obese patients is bariatric surgery (BS).(Buchwald et al., 2004; Maggard et al., 2005)
      Shermak et al. defined massive weight loss (MWL) as 50% or greater loss of excess
      weight.(Shermak et al., 2006) Next to the amelioration of the medical comorbidities
      associated with obesity, patients also benefit from improvement in their psychosocial
      functioning, personal health perceptions and health-related quality of life.(Karlsson et al.,
      1998; Karlsson et al., 2007; Sarwer et al., 2008) A major drawback after BS is the
      persistence of large quantities of excess and inelastic skin and subcutaneous tissue. Thus,
      patients often experience skin irritations, mycotic infections and secondary self-imaging
      problems.(Reiffel et al., 2013; Vico et al., 2010) Body contouring (BC) surgery, usually
      excisional, includes (circumferential) abdominoplasty, breast reduction, panniculectomy,
      brachioplasty, and thigh lift. It removes the excess tissue which remains after massive
      weight loss and consecutively leads to a significant improvement in self-image and
      self-esteem, as well as mobility, overall daily functioning and hygiene.(Larsen et al., 2007;
      Song et al., 2006) These procedures are usually multiple and extensive. Thus, combining and
      reducing the number of such procedures while obtaining optimal results would be most
      beneficial to both the surgeon and the patient.(Ellabban and Hart, 2004; Hallock and
      Altobelli, 1985) For patients who seek BS, quality of life is an important issue. In a recent
      study by Modarressi et al. it has been shown that Roux-en-Y gastric bypass (RYGBP) improves
      the health-related quality of life (HRQoL). Furthermore, it was shown that HRQoL is directly
      related to weight loss and BC procedures further improves HRQoL in comparison to RYGBP alone,
      as evidenced by the Moorehead-Ardelt questionnaire.(Modarressi et al., 2013; Oria and
      Moorehead, 1998) Nevertheless, there is an urgent need to develop specific and
      well-constructed patient reported outcome (PRO) instruments in order to obtain reliable
      information regarding QoL and patient satisfaction following BC surgery in MWL
      patients.(Jabir, 2013)

      Clinical Data In the literature there are some inconsistent data regarding QoL scales after
      BC procedures.(Singh et al., 2012) Problems after MWL with excessive skin folds compromises
      body image and may negatively impact the physical and mental components of QoL.(Mitchell et
      al., 2008) Thus, theoretically, after removal of skin excess, the QoL scales should improve
      after BC procedures. Indeed, several studies have demonstrated improvements in QoL associated
      with BC surgery.(Coriddi et al., 2011; Pecori et al., 2007; Song et al., 2006; van der Beek
      et al., 2010) However, in a recent study by Singh et al., scales comprising the mental
      component were lower in the group of patients who received BC procedures, indicating impaired
      QoL.(Singh et al., 2012) Of those, role-emotional and social functioning were significantly
      lower than both the control and the post-bariatric surgery group, showing that those patients
      who elected to have BC procedures suffer from worsening inhibited social interactions.(Singh
      et al., 2012) It might be arguable that patients in the post-bariatric surgery group who
      elected not to undergo BC chose so because their QoL was already high.(Singh et al., 2012)
      Thus, counseling and education prior to plastic surgery is extremely important to ensure
      appropriate expectations for the patient in regard to scarring and the realistic scope that
      can be accomplished by surgery.(Singh et al., 2012) QoL, especially in women aged between 35
      to 64 years old, is the most affected domain in patients with BMI > 40kg/m2.(Larsson et al.,
      2002) This dissatisfaction motivates different behaviours, including exercise, weight loss
      and cosmetic surgery.(Sarwer et al., 2008) Thus, despite obesity is more prevalent in men, it
      might explain partially why women more frequently seek bariatric surgery.(Modarressi et al.,
      2013) Following BS, patients are initially enthusiastic to see cure of their diabetes,
      decreased pain in their joints and weight loss.(Colwell, 2010) Nevertheless, the skin does
      not contract with the volume loss.(Colwell, 2010) As soon as the weight has been stable for
      at least 6 months, plastic surgical evaluation seems to be appropriate.(Colwell, 2010) In
      general, the lower the BMI at the time of BC surgery, the better the result.(Langer et al.,
      2011) Usually, condouting procedures are preserved for those patients who attain a BMI less
      than or equal to 35.(Arthurs et al., 2007) To date, little is known about the frequency and
      proportions of patients who undergo BS and consequently receive BC surgery. Reasons for not
      undergoing body contouring procedures can be the lack of awareness regarding options and
      expense.(Reiffel et al., 2013) Documentation of functional problems, such as rashes, sexual
      dysfunction and difficulty with exercise are important in attempting to obtain insurance
      coverage for at least part of their surgery.(Arthurs et al., 2007) Panniculectomy, defined as
      removal of excess skin and fat in the abdomen without umbilical transpostion, is the surgical
      procedure most likely to be covered by insurance.

      Usually, truncal deformity is the most common presenting complaint of MWL patients, and the
      procedure of choice is a lower body lift.(Colwell, 2010) It is crucial to focus
      postoperatively on patient safety prioritizing in seroma prevention and deep vein thrombosis
      (DVT) prophylaxis. Reported complication rates postoperative range between 17-50% including
      wound-healing problems, haematoma, infection, necrosis or pulmonary embolism.(Vico et al.,
      2010) Furthermore, many of these patients have psychiatric problems, and thus counseling,
      especially in the perioperative period is extremely important.(Langer et al., 2011) The
      number of procedures that can safely be performed in one sitting depends on the patient's
      anatomy, the surgeon, the surgical facility and overall medical health.(Arthurs et al., 2007)
      The patient's BMI should be normal or slightly overweight. Otherwise, staging the procedures
      into two or more surgeries separated by 3-6 months is suggested.(Arthurs et al., 2007)
      Ideally, the operative time should be kept under six hours or below to minimize
      complications.(Langer et al., 2011) Obviously, if vectors of pull at surgery are in opposite
      directions, such as in an upper body lift and a belt lipectomy/lower body lift, these
      procedures should be performed separately.(Langer et al., 2011) In a study by Ellabban et
      al., 14 patients were evaluated who underwent BC operations using combined abdominoplasty and
      medial thigh reduction. The authors concluded that combined abdominoplasty with vertical
      medial thigh reduction is effective in correcting aesthetic and physical problems after
      massive weight reduction with an excellent predictable outcome.(Ellabban and Hart, 2004)
      Also, combined brachioplasty, thoracoplasty, and mammoplasty has proven to be safe,
      effective, and beneficial for both the surgeon and patient.(Hallock and Altobelli, 1985) In
      order to establish an evidence base to support the idea that BC is as much (or even more) a
      functional procedure as it is cosmetic, a flurry of studies assessing QoL and patient
      satisfaction following BC surgery has been resulted.(Jabir, 2013) The method of choice to
      assess QoL and patient satisfaction is to use patient specific psychometrically validated PRO
      measures.(Jabir, 2013) To date, none of the measures have been specifically developed for BC
      surgery patients. Instead, there is an urgent need to develop specific and well- constructed
      PRO instruments in order to obtain reliable information regarding QoL and patient
      satisfaction after BC surgery in MWL patients.(Jabir, 2013)

      STUDY OBJECTIVES The main objective of this research is to analyse QoL and patient
      satisfaction after BC surgery in MWL male and female patients.

      We hypothesize that >80% of the patients have a total score of +2.25 to +3 ("much better") or
      +0.75 to +2 ("better") in the Moorehead-Ardelt questionnaire. 66 patients of equal
      distribution and demographic characteristics after bariatric surgery but no secondary
      reconstructive procedure will serve as a control group.

      The associated research questions are as follows:

      What is the outcome in patients after BC surgery and MWL concerning:

      Hypotheses:

      Primary outcome:

      After a mean follow-up of 8.9±3.5 years after BC surgery we hypothesize that >90% of the 66
      patients will answer the survey. Based on the literature(Modarressi et al., 2013), we expect
      that >80% of the patients have a total score of +2.25 to +3 ("much better") or +0.75 to +2
      ("better") in the Moorehead-Ardelt questionnaire.
    

Intervention name(s): Body Contouring Surgery
Intervention type(s): Procedure
Intervention description(s): Patients after bariatric surgery (BS) and patients with no history of BS but after natural weight loss and some degree of skin laxity who underwent Body contouring will be included after written informed consent is obtained.
Other intervention name(s): Body Contouring Surgery is the excision of excess skin
Observational model: Case-Control
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Post-bariatric male and female patients and patients with no history of bariatric surgery
        but after natural weight loss and some degree of skin laxity who underwent body-contouring
        surgery between February 1999 and October 2009 at the Department of Plastic, Reconstructive
        and Aesthetic Surgery, Handsurgery, University Hospital of Basel will be included. Patients
        after BS with equal distributions and demographic characteristics but no secondary
        reconstructive procedures served as a control group.
      
Keywords: Bariatric surgery; Body contouring; Quality of life