Abstract
Background
Studies demonstrating the positive impact of body contouring on sustained weight loss in bariatric patients describe a narrow cohort. We sought to evaluate the impact of post bariatric body contouring procedures on sustained weight loss in minority race patients.
Methods
A retrospective review of bariatric surgery patients at a single institution was performed. Patients were grouped by: (1) those that underwent body contouring, (2) those that had consultation but did not undergo body contouring, and (3) those without consultation. Body mass index (BMI) and excess body weight loss (EBWL) over 7 years were the primary outcomes.
Results
2531 patients were analyzed, 350 in Group 1, 364 in Group 2, and 1817 in Group 3. At postoperative year 7, Groups 1 and 2 had average BMIs 4.71 and 2.31 kg/m2 lower than Group 3, respectively, while adjusting for covariates. After exclusion of 105 patients in Group 2 that were not offered body contouring due to inadequate weight loss, however, Group 2 had an average BMI 4.07 kg/m2 lower than Group 3 at postoperative year 7. During postoperative year 1, Group 1 had an average EBWL of 74.38%, which declined 1.51% yearly, and Group 2 had an average EBWL of 70.12%, which declined 1.86% yearly. After exclusion of the aforementioned patients, Group 2 had an average EBWL of 74.9% at postoperative year 1, which declined 1.88% yearly.
Conclusions
Body contouring after bariatric surgery did not impart a clinically significant, long-term sustained weight loss benefit in our cohort. In our study population, we found that patients identifying as Black had significantly worse sustained weight loss.
BACKGROUND
Obesity impacts an estimated 39.8% of the United States population and carries a cumbersome financial and health burden(1–5). While weight reduction has been shown to mitigate the negative impact of medical comorbidities associated with obesity, these benefits are only realized if weight loss is sustained over time(1, 3, 5). Patients who have not been successful in sustaining weight loss with diet and exercise alone are frequently referred for bariatric surgery. Although bariatric surgery can lead to massive weight loss, often times peak weight loss occurs approximately 2 years postoperatively and is followed by a steady increase in weight over subsequent years(6–9).
Massive weight loss leads to volume deflation and skin excess that may negatively impact physical activity, hygiene, clothing fit, urinary or sexual function, and aesthetic appearance; these patients often seek body contouring in an effort to reduce discomfort and functional impairment, as well as improve cosmetic appearance(10, 11). There have been several studies that demonstrate a positive association between quality of life and body contouring after bariatric surgery(12–18). Additionally, previous literature seems to support the notion that body contouring is associated with improved sustained weight loss, although a study by Martin-del-Campo et al. seems to conflict with this idea(19–25). However, these studies fail to address three crucial questions. First, what is the effect of body contouring on sustained weight loss in minority race and ethnic populations? Minority populations are disproportionately affected by obesity, including 47% of Hispanics and 46.8% of non-Hispanic blacks compared to 37.9% of non-Hispanic whites(4, 26). Secondly, is the benefit of sustained weight loss after body contouring observed for both sleeve gastrectomy and gastric bypass procedures? Although previous studies include both bypass and sleeve procedures, the independent effect of bariatric operation type on sustained weight loss after body contouring has not been evaluated(9, 27–31). Thirdly, how does weight loss after body contouring compare to patients that underwent plastic surgery consultation but did not have a body contouring procedure? It is known that patients who are referred for body contouring have had greater weight loss than those who are not referred; therefore, it is necessary to independently consider this comparison group.
METHODS
After obtaining Institutional Review Board approval, a retrospective review of all patients that underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass procedures at a single institution from 2009 to 2012 was performed. Patients that underwent revision of their bariatric procedure were excluded. The sample was divided into three groups: (1) those that underwent body contouring procedures, (2) those that had consultation for body contouring but did not undergo a procedure, and (3) those without consultation.
Patients were analyzed based on the following characteristics: age, sex, race, body mass index (BMI), excess body weight loss (EBWL), bariatric procedure technique, and body contouring procedure. Weights were recorded at yearly intervals for up to seven years postoperatively. Ideal body weight calculations were performed using sex-specific formulas described by Miller(32). Excess body weight was calculated as the difference between actual and idea body weight. Socioeconomic status data was obtained when available, and was calculated using a method described by Diez Roux et al(33).
Statistical Analysis
Statistical analyses were computed using Stata Version 16.1 (College Station, TX: StataCorp LLC) and graphs were generated using IBM® SPSS® Statistics Version 25 (IBM Corp., Armonk, N.Y.). Bivariate analysis was performed using chi-square tests and one-way ANOVA, with Scheffe’s post hoc testing performed for any statistically significant comparisons; if no statistically significant p values were observed on post-hoc texting, the omnibus p value was reported. In order to address the repeated nature of subject-specific weight measurements, and to allow for analysis of subjects with missing data points, linear mixed effects models were created. Data trends over time were visually evaluated using mean plots. When a shift in measurement slope was noted on mean plot, linear spline models were used with a knot introduced at the appropriate time point. Visual inspection of variograms and Akaike information criterion (AIC) were utilized to determine the most appropriate covariance structure for each model, and unstructured covariance structures were ultimately utilized given the observed inter-subject heterogeneity. Sensitivity analyses were performed for each model after patients that were referred for plastic surgery consultation but deemed unsuitable body contouring candidates secondary to insufficient weight loss were removed. All test assumptions were assessed, and violations of test assumptions were appropriately addressed. Alpha was set at 0.05.
RESULTS
A total of 2531 patients that underwent bariatric procedures were analyzed. The average age of the study population was 40.6±11.3 years and the average pre-bariatric BMI was 46.8±7.7 kg/m2.
Comparison of Group Demographics and Operative Characteristics
Baseline patient characteristics were compared between those that underwent body contouring (Group 1; n=350[13.8%]), that underwent plastic surgery consultation without body contouring (Group 2; n=364[14.4%]), and those that were not referred for plastic surgery consultation (Group 3; n=1817[71.8%]) (Table 1). The comparison of mean preoperative BMI between groups suggested a significant difference in BMI on omnibus testing (p=0.04), however on post hoc testing no significant difference was detected. There was a significantly greater prevalence of females in Groups 1 and 2 as compared to Group 3 (92.9% & 91.8% vs. 82.2%, p<0.001). Additionally, patients in Groups 1 and 2 underwent significantly more gastric bypass procedures (versus sleeve gastrectomy) as compared to Group 3 (68.0% & 68.7% vs. 58.6%, p<0.001). The distribution of self-identified race/ethnicity also significantly differed between groups (p<0.001), with a greater percentage of patients in Group 1 identifying as Hispanic or Latinx than in Group 2 or 3 (74.9% vs. 63.7% vs. 59.4%), and a fewer percentage identifying as Black (15.4% vs. 25.3% vs. 27.1%).
Table 1.
Group comparisons of patient demographics.
| Group One: Bariatric Surgery + Body Contouring (n = 350) | Group Two: Bariatric Surgery + Plastic Surgery Consultation (n = 364) | Group Three: Bariatric Surgery Only (n = 1,817) | P value | |
|---|---|---|---|---|
| Age, years | 39.7 ± 10.6 | 41.6 ± 10.8 | 40.6 ± 11.5 | 0.09 |
| Female | 325 (92.9) | 334 (91.8) | 1,494 (82.2) | <0.001 |
| Race | <0.001 | |||
| Black | 54 (15.4) | 92 (25.3) | 492 (27.1) | |
| Hispanic/Latinx | 262 (74.9) | 232 (63.7) | 1,080 (59.4) | |
| White | 15 (4.3) | 20 (5.5) | 88 (4.8) | |
| Asian | 1 (0.3) | 0 (0.0) | 8 (0.4) | |
| Other | 7 (2.0) | 8 (2.2) | 44 (2.4) | |
| Declined | 11 (3.1) | 12 (3.3) | 105 (5.8) | |
| Gastric bypass (ref: sleeve gastrectomy) | 238 (68.0) | 250 (68.7) | 1,065 (58.6) | <0.001 |
| Preoperative body mass index, kg/m 2 | 45.9 ± 7.7 | 47.2 ± 8.3 | 46.9 ± 7.5 | 0.04 |
Reported as mean ± SD or n (%).
A total of 522 body contouring procedures were performed on 342 patients. Median time to body contouring was 2.1 years (IQR: 1.6–2.7). Abdominoplasty/panniculectomy were the commonest procedures performed, with a prevalence of 317 operations (60.7%) (Table 2). The second most common procedure performed was mammaplasty (n=114[21.8%]), followed by brachioplasty (n=65[12.5%]), and thighplasty (n=26[5.0%]).
Table 2.
Summary of total body contouring procedures.
| Body Contouring Procedure | Summary Statistic (n=522) |
|---|---|
| Abdominoplasty/panniculectomy | 317 (60.7) |
| Brachioplasty | 65 (12.5) |
| Mammaplasty | 114 (21.8) |
| Thighplasty | 26 (5.0) |
Reported as n (%).
A total of 522 procedures were performed on 342 patients.
Longitudinal Analysis of Postoperative Body Mass Index and Excess Body Weight Loss
Both BMI and EBWL were trended yearly over 7 years by each comparison group. A mean plot of BMI demonstrates a nadir at postoperative year 1 for Group 3 and at 2 years postoperatively for Groups 1 and 2, followed by a linear increase in BMI over the remainder of the study period (Fig 1). Similarly, a mean plot of EBWL demonstrates maximal weight loss at postoperative year 1 for Group 3 and at postoperative year 2 for Groups 1 and 2, followed by linear decrease in EBWL over the remainder of the study period (Fig 2). For all postoperative years, Group 1 had a lesser mean BMI (and greater EBWL) than Group 2, which had a lesser mean BMI (and greater EBWL) than Group 3.
Figure 1.
Yearly body mass index trend immediately before and seven years after bariatric surgery. Error bars represent standard error.
Figure 2.
Yearly excess body weight loss trend for seven years after bariatric surgery. Error bars represent standard error.
A linear mixed effects spline model with a knot at postoperative year 1 was created in order to examine the association between BMI and body contouring over time while adjusting for potential confounders. Prior to or during postoperative year 1, the mean response for Group 1 equated 45.99–0.48+(−2.49–14.34)(year); with respect to the reference group at postoperative year 1, for example, Group 1 had an average BMI 2.97 kg/m2 lower than Group 3 (Table 3). After postoperative year 1, the mean response for Group 1 equated 45.99–0.48+(−2.49–14.34+14.93+2.20)(year)–(14.93+2.20)(y*); for example, during postoperative year 7 the body contouring group had an average BMI 4.71 kg/m2 lower than the bariatric only group. Prior to or during postoperative year 1, the mean response for Group 2 equated 45.99+0.60+(−2.07–14.34)(year); with respect to the reference group at postoperative year 1, for example, Group 2 had an average BMI 1.47 kg/m2 lower than Group 3 (Table 3). After postoperative year 1, the mean response for Group 2 equated 45.99+0.60+(−2.07–14.34+14.93+1.93)(year)–(14.93+1.93)(y*); for example, during postoperative year 7 the plastic surgery consultation group had an average BMI 2.31 kg/m2 lower than the bariatric only group. Likewise, the mean response prior to or during postoperative year 1 for those that underwent sleeve gastrectomy is given by 45.99–1.03+(2.42–14.34)(year); at postoperative year 1, those that underwent sleeve gastrectomy had an average BMI 1.39 kg/m2 greater than those that underwent gastric bypass. During or after postoperative year 1, the mean response for those that underwent sleeve gastrectomy is described by 45.99–1.03+(2.42–14.34+14.93–2.27)(year)–(14.93–2.27)(y*); at postoperative year 7, those that underwent sleeve gastrectomy had an average BMI 2.29 kg/m2 greater than those that underwent gastric bypass. With respect to self-identified race, the mean BMI response at postoperative year 1 for patients identifying as Black was 2.70 kg/m2 greater than those identifying as Hispanic/Latinx, whereas those identifying as White had a BMI 0.18 kg/m2 greater than the reference group; at postoperative year 7, these BMI differences were 2.28 and 0.6 kg/m2, respectively. On sensitivity analysis, 105 patients that had plastic surgery consultation but were not offered body contouring due to inadequate weight loss were excluded. During postoperative year 1, Group 1 had an average BMI of 28.74 kg/m2 and Group 2 had an average BMI of 28.57 kg/m2, which are both lower than 31.74 kg/m2, the mean BMI of those in Group 3. During postoperative year 7, Group 1 had an average BMI of 30.42 kg/m2 and Group 2 had an average BMI of 31.09 kg/m2, whereas Group 3 had a mean BMI of 35.16 kg/m2.
Table 3.
Linear mixed effects spline model with a knot at time = 1 year postoperatively for the outcome of body mass index.
| Variable | Coefficient | 95% Confidence Interval | P value |
|---|---|---|---|
| Group (ref: only bariatric surgery) | |||
| Body contouring | −0.48 | −1.35 – 0.39 | 0.28 |
| Plastic surgery consultation | 0.60 | −0.25 – 1.46 | 0.17 |
| Sleeve gastrectomy (ref: gastric bypass) | −1.03 | −1.64 – −0.43 | 0.001 |
| Race (ref: Hispanic/Latinx) | |||
| Black | 2.04 | 1.34 – 2.74 | <0.001 |
| White | 0.37 | −1.03 – 1.76 | 0.61 |
| Asian | −1.63 | −6.57 – 3.31 | 0.52 |
| Other | 4.21 | 2.25 – 6.17 | <0.001 |
| Declined | 0.80 | −0.56 – 2.16 | 0.25 |
| Male (ref: female) | 3.41 | 2.57 – 4.25 | <0.001 |
| Postoperative year 0–1, per 1 year | −14.34 | −14.72 – −13.96 | <0.001 |
| Postoperative year 2–7, per 1 year | 14.93 | 14.52 – 15.34 | <0.001 |
| Constant | 45.99 | 45.49 – 46.50 | <0.001 |
| Interaction with postoperative year 0–1 | |||
|
| |||
| Year*Group (ref: only bariatric surgery) | |||
| Body contouring | −2.49 | −3.12 – −1.86 | <0.001 |
| Plastic surgery consultation | −2.07 | −2.69 – −1.46 | <0.001 |
| Year*Sleeve gastrectomy (ref: gastric bypass) | 2.42 | 1.96 – 2.87 | <0.001 |
| Year*Race | |||
| Black | 0.66 | 0.15 – 1.18 | 0.01 |
| White | −0.19 | −1.22 – 0.84 | 0.71 |
| Asian | −0.49 | −4.24 – 3.25 | 0.80 |
| Other | −1.25 | −2.73 – 0.23 | 0.10 |
| Declined | −0.57 | −1.61 – 0.47 | 0.28 |
| Year*Male (ref: female) | −1.09 | −1.72 – −0.46 | 0.001 |
| Interaction with postoperative year 2–7 | |||
|
| |||
| Year*Group (ref: only bariatric surgery) | |||
| Body contouring | 2.20 | 1.53 – 2.86 | <0.001 |
| Plastic surgery consultation | 1.93 | 1.27 – 2.59 | <0.001 |
| Year*Sleeve gastrectomy (ref: gastric bypass) | −2.27 | −2.75 – −1.79 | <0.001 |
| Year*Race | |||
| Black | −0.73 | −1.27 – −0.18 | 0.01 |
| White | 0.17 | −0.93 – 1.27 | 0.77 |
| Asian | 0.35 | −3.74 – 4.44 | 0.87 |
| Other | 1.16 | −0.42 – 2.74 | 0.15 |
| Declined | 0.65 | −0.47 – 1.77 | 0.26 |
| Year* Male (ref: female) | 1.12 | 0.45 – 1.80 | 0.001 |
| Random effects | |||
|
| |||
| Variance, postoperative year 0–1 | 22.10 | 20.46 – 23.87 | - |
| Variance, postoperative year 2–7 | 23.28 | 21.44 – 25.28 | - |
| Covariance, postoperative years 0–1 and 2–7 | −22.30 | −24.09 – −20.51 | - |
The interpretation of Table 4, which examines the outcome of EBWL, is analogous to the model utilizing BMI as the outcome, with the major difference being that there is no spline, and that postoperative year 1 is the reference year. During postoperative year 1 those in the body contouring group had an average EBWL of 74.38%, and this weight loss slowly declined by 1.51% per year. Similarly, at postoperative year 1 those in the plastic surgery consultation group had an average EBWL of 70.12%, and this weight loss slowly declined by 1.86% per year. On sensitivity analysis, Group 1 group had an average EBWL of 74.13% at postoperative year 1, and this weight was regained by 1.48% per year, while Group 2 had an average EBWL of 74.9% at postoperative year 1, and this weight was regained by 1.88% per year. Given that the interaction between race and time was not significant, these time-dependent terms were not included in the model. As compared to patients identifying as Hispanic/Latinx, those identifying as Black had significantly worse EBWL (−7.09 [95%CI: −8.84 – −5.34]); no other race coefficients significantly differed from the reference group.
Table 4.
Linear mixed effects model of the outcome of weight loss as a percentage of excess body weight.
| Variable | Coefficient | 95% Confidence Interval | P value |
|---|---|---|---|
| Group (ref: only bariatric surgery) | |||
| Body contouring | 10.63 | 8.23 – 13.04 | <0.001 |
| Plastic surgery consultation | 6.37 | 3.99 – 8.74 | <0.001 |
| Sleeve gastrectomy (ref: gastric bypass) | −6.97 | −8.73 – −5.21 | <0.001 |
| Race (ref: Hispanic/Latinx) | |||
| Black | −7.09 | −8.84 – −5.34 | <0.001 |
| White | 0.11 | −3.40 – 3.61 | 0.95 |
| Asian | 5.81 | −6.88 – 18.50 | 0.37 |
| Other | −3.48 | −8.54 – 1.58 | 0.18 |
| Declined | 0.06 | −3.49 – 3.61 | 0.97 |
| Male (ref: female) | −4.66 | −6.82 – −2.50 | <0.001 |
| Postoperative year 1–7, per 1 year | −2.50 | −2.82 – −2.18 | <0.001 |
| Constant | 63.75 | 62.29 – 65.20 | <0.001 |
| Interaction with postoperative year 1–7 | |||
|
| |||
| Year*Group (ref: only bariatric surgery) | |||
| Body contouring | 0.99 | 0.42 – 1.56 | 0.001 |
| Plastic surgery consultation | 0.64 | 0.08 – 1.21 | 0.03 |
| Year*Sleeve gastrectomy (ref: gastric bypass) | −0.59 | −1.02 – −0.15 | 0.01 |
| Random effects | |||
|
| |||
| Variance, postoperative year 1–7 | 14.42 | 13.05 – 15.92 | - |
Year 1 is the reference year.
Of note, soscioeconomic status (SES) was available for 169 patients in Group 1 (SES=−4.55±2.93) and 193 patients in Group 2 (SES=−4.12±2.67), and there was no statistically significant different between the two (p=0.14).
Subgroup Analysis of Patients that Underwent Body Contouring
To examine the association between bariatric procedure and weight loss solely in those that underwent body contouring, a subgroup analysis was performed. Adjusting for sex and resection weight, those that underwent sleeve gastrectomy had a mean BMI response described by 40.37–1.73+(2.43–14.62)(year) during postoperative years 0 and 1, and a mean BMI response of 40.37–1.73+(2.43–14.62+15.05–2.20)(year)–(15.05–2.20)(y*) during postoperative years 2–7; for example, during postoperative year 1, those that underwent sleeve gastrectomy had an average BMI 0.7 kg/m2 greater than those that underwent gastric bypass, and during postoperative year 7 the average BMI in the sleeve gastrectomy group was 2.08 kg/m2 greater than the gastric bypass group (Table 5). With respect to EBWL during postoperative years 1–2 (where postoperative year 1 is the reference group), the sleeve gastrectomy subgroup mean response was described by 71.75–0.49+(4.27–3.52)(year-1), and during postoperative years 3–7 the mean response was given by 71.75–0.49+(4.27–3.52+2.71–6.79)(year)−(2.71–6.79)(y*−1); for instance, during postoperative year 2, those that underwent sleeve gastrectomy had an EBWL 4.01% lower than those that underwent gastric bypass, and during postoperative year 7, those that underwent sleeve gastrectomy had an EBWL 8.06% lower than those that underwent gastric bypass (Table 6).
Table 5.
Subgroup analysis of patients that underwent body contouring using linear mixed effects spline model with a knot at time = 1 year postoperatively for the outcome of body mass index.
| Variable | Coefficient | 95% Confidence Interval | P value |
|---|---|---|---|
| Sleeve gastrectomy (ref: gastric bypass) | −1.73 | −3.25 – −0.20 | 0.03 |
| Male (ref: female) | 6.14 | 3.42 – 8.85 | <0.001 |
| Total resection weight, per 1 lb | 1.12 | 0.88 – 1.37 | <0.001 |
| Postoperative year 0–1, per 1 year | −14.62 | −15.77 – −13.46 | <0.001 |
| Postoperative year 2–7, per 1 year | 15.05 | 13.86 – 16.23 | <0.001 |
| Constant | 40.37 | 38.88 – 41.86 | <0.001 |
| Interaction with postoperative year 0–1 | |||
|
| |||
| Year*Sleeve gastrectomy (ref: gastric bypass) | 2.43 | 1.25 – 3.62 | <0.001 |
| Year*Male (ref: female) | −3.82 | −5.94 – −1.69 | <0.001 |
| Year*Total resection weight, per 1 lb | −0.41 | −0.60 – −0.22 | <0.001 |
| Interaction with postoperative year 2–7 | |||
|
| |||
| Year*Sleeve gastrectomy (ref: gastric bypass) | −2.20 | −3.41 – −0.98 | <0.001 |
| Year*Male (ref: female) | 3.98 | 1.78 – 6.17 | <0.001 |
| Year*Total resection weight, per 1 lb | 0.38 | 0.18 – 0.57 | <0.001 |
| Random effects | |||
|
| |||
| Variance, postoperative year 0–1 | 20.71 | 17.00 – 25.21 | - |
| Variance, postoperative year 2–7 | 20.26 | 16.38 – 25.06 | - |
| Covariance, postoperative years 0–1 and 2–7 | −20.20 | −24.36 – −16.05 | - |
Table 6.
Subgroup analysis of patients that underwent body contouring using linear mixed effects spline model with a knot at time = 2 years postoperatively for the outcome of weight loss as a percentage of excess body weight.
| Variable | Coefficient | 95% Confidence Interval | P value |
|---|---|---|---|
| Sleeve gastrectomy (ref: gastric bypass) | −0.49 | −5.74 – −4.76 | 0.86 |
| Race (ref: Hispanic/Latinx) | |||
| Black | −7.39 | −11.24 – −3.53 | <0.001 |
| White | −6.51 | −13.32 – 0.31 | 0.06 |
| Asian | 10.15 | −15.50 – 35.80 | 0.44 |
| Other | −6.18 | −15.86 – 3.50 | 0.21 |
| Declined | −4.90 | −13.64 – 3.85 | 0.27 |
| Total resection weight, per 1 lb | −1.34 | −1.83 – −0.86 | <0.001 |
| Postoperative year 1–2, per 1 year | 4.27 | 2.55 – 5.99 | <0.001 |
| Postoperative year 3–7, per 1 year | −6.79 | −8.67 – −4.90 | <0.001 |
| Constant | 71.75 | 67.82 – 75.67 | <0.001 |
| Interaction with postoperative year 1–2 | |||
|
| |||
| Year*Sleeve gastrectomy (ref: gastric bypass) | −3.52 | −6.53 – −0.50 | 0.02 |
| Interaction with postoperative year 3–7 | |||
|
| |||
| Year*Sleeve gastrectomy (ref: gastric bypass) | 2.71 | −0.62 – 6.04 | 0.11 |
| Random effects | |||
|
| |||
| Variance, postoperative year 1–2 | 81.07 | 58.67 – 112.02 | - |
| Variance, postoperative year 3–7 | 84.26 | 58.16 – 122.05 | - |
| Covariance, postoperative years 1–2 and 3–7 | −77.84 | −105.84 – −49.85 | - |
Year 1 is the reference year.
DISCUSSION
We demonstrate that bariatric patients undergoing body contouring procedures maintain a lower BMI and greater weight loss over 7 years after index operation than those that undergo bariatric surgery alone. Our findings suggest that the etiology of this sustained weight loss may not be secondary to body contouring, however, as the weight loss difference between body contouring patients and those that had plastic surgery consultation but did not undergo body contouring is clinically insignificant.
During postoperative year 1, which is generally prior to when any body contouring procedures were performed, patients that would eventually undergo body contouring had a mean adjusted BMI that was 3.0 kg/m2 lower than those in the “bariatric only” group. This finding is expected as sufficient weight loss after bariatric surgery is a prerequisite to body contouring. During this same timeframe, patients that were referred for plastic surgery consultation but would not undergo body contouring had a mean adjusted BMI that was 1.5 kg/m2 lower than the reference group, however when the 105 patients that were not approved for body contouring secondary to inadequate weight loss were excluded the mean adjusted BMI was 3.3 kg/m2 lower than the reference group. Given that the primary objective of this study was to examine the independent effect of body contouring on weight loss in bariatric patients, we considered the revised plastic surgery consultation group to be the most appropriate comparison. At postoperative year 7, the mean adjusted BMI in the body contouring group was 4.7 kg/m2 lower than the reference group whereas the mean adjusted BMI in the revised plastic surgery consultation group was 4.1 kg/m2 lower than the reference group. Likewise, the mean adjusted EBWL at postoperative year 1 was 74.4% for the body contouring group and 70.1% for the plastic surgery consultation group, however when patients were excluded from the plastic surgery consultation group the EBWL was 74.9%. The yearly EBWL regain in the body contouring group was 1.5%, which is similar to the regain of 1.9% in the revised plastic surgery consultation group and only results in a difference of 2.4% at postoperative year 7. Of note, the mean adjusted EBWL in the “bariatric only” group was 63.8% at postoperative year 1, and was regained at a yearly rate of 2.5%. Given the similarity of the mean BMI and EBWL responses between the body contouring group and the plastic surgery consultation group, we conclude that the impact of body contouring on weight loss is likely minimal, and the difference in weight loss as compared to the “bariatric only” group is secondary to individual patient factors.
These findings differ from previous studies. For instance, Balagué et al. reported a mean EBWL difference of 28.5% between body contouring patients and plastic surgery consultation patients 7 years after gastric bypass(19). This drastically differs from our difference in EBWL between these groups of 2.4% at postoperative year 7. The etiology of this difference may be multifaceted. In their discussion, Balagué and co-investigators note an important limitation in that wealthier patients may be more likely to undergo body contouring procedures, as those that did not undergo body contouring cited financial barriers as the primary reason for not pursuing surgical intervention. Our study cohort consists of a predominantly underserved, minority race population with primarily Medicaid insurance coverage, which likely mitigates this selection bias. Additionally, we did not find a significant difference in SES between patients that had body contouring and those that had plastic surgery consultation. Studies by Agarwal et al. and Froylich et al. also report a potential positive impact of body contouring on sustained weight loss after bariatric surgery, however they do not utilize a control group consisting of patients that had plastic surgery consultation(20, 21). A study by Martin-del-Campo et al. does report that the metabolic impact of body contouring on massive weight loss patients dissipates after 2 years postoperatively, however this study is limited by its small sample size and relatively short follow-up time(25).
Our study consists of 29.2% of patients identifying as Black and 62.2% of patients identifying as Hispanic or Latinx. This is the largest know study to date that evaluates the individual impact of race on the association between body contouring, bariatric surgery, and sustained weight loss. In our study population, we found that patients identifying as Black had significantly worse sustained weight loss. The association between weight and race is undoubtedly an indirect one, as race is a societal construct that reflects numerous variables not captured in this study. Nevertheless, it is crucial to address this association between race and sustained weight loss, as increased awareness to this arena will ultimately contribute to its rectification.
Prior studies have not explicitly evaluated the effect of body contouring in post-sleeve gastrectomy patients. We found patients that underwent sleeve gastrectomy had significantly worse sustained weight loss than gastric bypass patients. Among body contouring patients, the mean difference in EBWL between the bariatric procedures was 8.1% at 7 years postoperatively. The decision to pursue one bariatric technique over the other must me made in light of other information, such as improved gastric reflux status in gastric bypass patients, or decreased reoperation rate in sleeve gastrectomy patients(30).
This study has several limitations. First, its retrospective design does not allow for standardized data collection, meaning that patients did not have regular interval follow up. It is likely that body contouring procedures performed at out-of-network hospitals, or by private practicioners, were not captured in our chart review. The implication of this may not be substantial however, since these patients ultimately would be lost to follow up and therefore not contribute much in the way of outcome data. Nonetheless, this yields a selection bias that must be mentioned. Secondly, there is a substantial amount of missing data, which is not unexpected given the length of follow-up. However, the large sample size and robust analytic methods mitigate the impact of these missing data. Thirdly, there may be selection bias resulting from which patients are referred for plastic surgery consultation, as well as in which patients are denied body contouring. Although we examine the reason cited for not undergoing body contouring, perform sensitivity analyses, and compare SES between groups, there are likely latent confounders not captured in this study.
CONCLUSIONS
Our findings suggest that in a chiefly minority race, urban population, body contouring after bariatric surgery does not impart a clinically significant, long-term sustained weight loss benefit. The benefit of body contouring in massive weight loss patients is likely psychosocial, and improves physical functionality. Additionally, we observed gastric bypass procedures to be associated with improved long-term weight loss as compared to sleeve gastrectomy.
Acknowledgements
This study was supported by the NIH/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore CTSA Grant Number TL1 TR001072.
Footnotes
Presented at:
Northeastern Society of Plastic Surgeons Annual Meeting, October 4–6, 2019, Pittsburgh, PA.
The American Association of Plastic Surgeons 99th Annual Meeting, May 15–18, 2021, Miami, FL.
Financial Disclosure Statement
The authors have no financial interest to declare in relation to the content of this article.
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