Micro- and macroscopic structural modification of subcutaneous adipose tissue after bariatric surgery

We found the article by Levy et al. [1] entitled Macroscopic Anatomic Changes of Subcutaneous Fat Tissue in Massive-Weight Loss Patients, recently published in your online journal, very interesting. It is a relevant article from a scientific point of view and extremely useful in terms of surgical repeatability. As clearly mentioned in the article, obesity currently is a worldwide disease, with several physical and psychological consequences [2–4] affecting both developed and developing countries. Because of scarce compliance to physical exercise and diet prescriptions, obese, and particularly severely obese individuals, are unable to achieve a proper and durable weight loss. By contrast, bariatric surgery has shown long-term effectiveness in treating morbid obesity, allowing great and stable weight loss. However, one of its side effects is represented by hanging and redundant skin, which is responsible for functional and psychological disturbance for the patients. Such unaesthetic deformities are correctable only with plastic surgery in the form of reconstructive body contouring. Despite this, modifications in the tissue composition of surgical massive weight loss patients can be noticed. These patients typically experience a higher rate of surgical complications than the standard population, which can be partly explained by these alterations [5]. Based on the anatomic data from the study performed by Levy et al. [1], after gastric banding, a restrictive bariatric procedure, significant macroscopic alterations of the adipose tissue were found in all four areas they examined (epigastric, umbilical, hypogastric and lumbar regions). These alterations were loss of the superficial fascial system (with infiltration by white, atrophic, and hyperplastic adipose cells) and discontinuation of the areolar and lamellar layers. Our experience with body contouring for massive weight loss after bariatric surgery is linked primarily to biliopancreatic diversion, a mainly malabsorptive bariatric procedure. Nevertheless, our macroscopic observations are similar to those obtained by Levy et al. [1]: penetration of the superficial fascial system by white atrophic adipose cells combined with gelatinous consistency and absence of compactness of the subcutaneous tissue (Fig. 1). We underscore how the aforementioned anatomic changes, in our case, were associated with microscopic modifications, as shown in our previous study [5] evaluating the problematic wound-healing process in postbariatric patients. In fact, using evidence by Weigert–Van Gieson stain for elastic fibers and connectivum applied on the cutaneous and subcutaneous tissue taken from the horizontal scar during abdominoplasty, we documented anomalies of the dermal elastic (overgrowth, disarray, greater dimensions, serpiginous and polyfragmented aspect, occasional increment in number) and collagen (thickened, hyperosinophilic, and sclerodermoid) fibers. Moreover, we noted modifications involving the subcutaneous tissue: diffuse sclerosis, collapsed adipocytes, fibrous septum thickening, and pseudocysts. Finally, in the extracellular matrix, there was evidence of persistent inflammation (Fig. 2). M. D’Ettorre (&) R. Bracaglia D. Tambasco S. Gentileschi Department of Plastic and Reconstructive Surgery, Catholic University, Largo A. Gemelli, 8, 00168 Rome, RM, Italy e-mail: marco.dettorre@hotmail.it