Body Contouring Following Massive Weight Loss

Abstract

The growing prevalence of obesity in America has led to an increase in bariatric surgery, which produces successful long-term weight loss and improves the multiple co-morbidities caused by obesity. A weight loss of 100+ pounds leaves patients with significant amounts of loose-hanging excess skin and tissue that can be addressed only with surgery. This article briefly describes many body contouring procedures developed by plastic surgeons to address the needs of massive weight loss patients.

Introduction

The overall prevalence of obesity among adults in the United States was reported to be 34% during the 2007–2008 period with obesity defined as a Body Mass Index of 30 or higher.¹ Another 34% of the adults are overweight (a BMI of 25.0 to 29.9). Thus, fewer than one-third (32%) of Americans have a normal or lower BMI. The number of adults with “severe” or “morbid” obesity (BMI ≥40, or ≥35 if a person has an obesity-related disease) has risen to 5.7% overall and is more than twice as high in non-Hispanic black women (14.2%). Recently, researchers have defined a new classification called the super obese (BMI ≥50).

No physician will oppose obesity control as a national priority. If successful, it will reduce health care costs, premature deaths, and the range of co-morbidities associated with obesity, such as hypertension, type II diabetes, cardiovascular disease, lipid metabolism disorders, pulmonary complications, liver disease, obstructive sleep apnea, degenerative joint disease, and increased cancer rates. Multiple studies and meta-analyses have determined that the most effective treatment for long-lasting weight loss and improvement or resolution of the multiple diseases caused by morbid obesity is bariatric surgery.^{2, 3, 4, 5} According to the American Society for Metabolic & Bariatric Procedures, weight loss surgery was performed on about 220,000 Americans in 2008, an increase from 63,100 in 2002.⁶

The Role of Plastic Surgery Following Weight Loss

The success of bariatric surgery has led to the emergence of a new sub-specialty within plastic surgery for patients who have lost massive amounts of weight, typically 100 pounds or more. Although a majority of this patient population has undergone bariatric surgery, others lose weight through lifestyle changes, including strict healthy diets and exercise programs. Regardless of the weight loss method, the resulting body contour deformities are unlike those typically seen by plastic surgeons. Significant sagging skin folds remain after weight loss and may develop at multiple and often unexpected body locations.

Many weight loss patients have been told that excess skin may be a problem, but most are unprepared for where and how much there will be.⁷ In addition, patients often have localized pockets of subcutaneous fat resistant to weight loss that also have a negative impact on their body contour and self-image. To address such deformities, plastic surgeons have developed and refined many new body contouring procedures. Although only a limited number of plastic surgeons are involved with this emerging sub-specialty, it is progressing rapidly, with growing numbers of procedures being described regularly.^{8, 9, 10}

According to statistics compiled by the American Society of Plastic Surgeons, nearly 59,000 body contouring procedures were performed on massive weight loss patients in 2008.¹¹ In some ways, body contouring may be properly considered as aesthetic because it improves appearance, but it is also reconstructive in that it completes rehabilitation from obesity. Patients with the most pronounced contour deformities tend to be those who have lost half (or more) of their maximum weight. Not surprisingly, those who seek plastic surgery tend to be of younger age, mostly female who are more often divorced than married.¹²

In addition to dealing with the serious body image issues that frequently accompany obesity and continue after weight loss, patients may seek plastic surgery to improve physical and hygienic functions, which are known to have positive effects on the quality of life.^{13, 14} Simple mobility, not to mention exercise, remains difficult after losing significant weight because movement is impeded by long hanging envelopes of skin. Sexual function is similarly impaired. Many patients develop persistent irritations and/or bacterial or fungal infections in deep skin folds beneath the abdominal pannus, mons pubis, or breasts caused by two skin surfaces rubbing against each other and the continuous presence of moisture. The burden of carrying around a large and heavy flap of redundant skin is often accompanied by skeletal pain, particularly in patients with a large pannus, which looks much like an apron of skin and may extend to the knees or below. Surgical removal of the excess skin is the only permanent solution to such problems.

The loss of large volumes of fat means the skin has lost much of its subcutaneous support and therefore looks deflated. After years of being stretched, the skin becomes inelastic and can no longer retract to fit the contour of the smaller volume beneath. Patients are most often bothered by the excess skin in areas of the lower abdomen, breast, axilla, buttocks, upper arms, and thighs. Loose, hanging skin may also be evident in the face and neck, upper abdomen, back and flank regions, and even forearms or calves. Despite the successful weight loss, patients frequently remain unhappy with their self-image, and the appearance of the new deformities may be at least as unappealing as the obese body. Moreover, the excess skin must be accommodated by clothing, which is ill-fitting and larger than they expected after weight loss. The smaller sizes and more stylish clothes patients thought they would be able to wear are still out of reach unless body contouring is performed.

Massive weight loss patients have struggled with obesity and its associated health problems for many years and faced the discrimination that often confronts them. They assumed responsibility for their health and took dramatic steps to lose the weight that was killing them.¹⁵ Despite their suffering to lose weight, the hanging skin serves as a constant reminder of years of obesity. For them, the transformation following weight loss is not complete as long as the large skin folds remain. Despite losing about half their body weight, many of our patients continue to view themselves as “fat” until their body contouring is complete and they can see their real size. At that point, a new world of possibilities opens before them: they may finally be able to play with their children, start dating, enjoy improved job prospects or promotions, and move through life as a “normal” person.

Patient Selection

Before beginning body contouring, patients should have reached and maintained a plateau in their weight loss, which takes between 12 to 24 months after bariatric surgery. The health benefits of massive weight loss arise primarily from the reduction of intra-abdominal visceral fat. As the many co-morbidities associated with excessive visceral fat improve or resolve, patients may more safely undergo body contouring surgery, which often takes many hours. Preoperative medical clearance from the primary care physician or internist should be obtained to screen for potential hematologic, cardiac, metabolic, and pulmonary problems as well as to evaluate nutritional status.^{16, 17} Recovery from major body contouring procedures can be a challenge, especially for those with incisions long enough to be measured in meters rather than centimeters. Surgical complications are not uncommon in post-weight loss body contouring patients as poor skin quality and nutritional depletion delay wound healing.^{9, 17, 18, 19} Major complications, however, are rare. As a general rule, patients closer to their ideal body weight have a lower risk of complications and a greater chance of a good aesthetic outcome.

Most bariatric surgery centers ensure that patients have undergone preoperative counseling and are psychologically stable, committed to changing their lifestyles, educated about nutrition, and encouraged to join a support group. When these patients reach the plastic surgeon they are highly motivated to improve their appearance and function and most will have realistic expectations. Patients who have lost a significant amount of weight must understand that they will not have the body contour of people who were never obese. Postural deformities that remain after weight loss should be identified because long-standing skeletal and postural changes that develop over years of carrying excessive body weight are intractable to body contouring surgery.²⁰ Thus, the enlarged rib cage (“barrel chest”), thoracic kyphosis (“hump-back”), eversion of the pelvis, and widened stance are likely to remain. The surgeon must also explain that the scars resulting from body contouring procedures are typically lengthy, though most are well hidden. Moreover, skin ptosis is likely to recur to some degree since skin elasticity cannot be restored. For all these reasons, the informed consent process is lengthy with this patient population.

Deformities Following Weight Loss

Working with weight loss patients has taught plastic surgeons that people do not lose weight uniformly. Subcutaneous fat loss accompanies the loss of visceral fat, but patients are often left with areas of localized lipodystrophies. Patients with a “pear-shaped” body habitus tend to have more residual fat and greater deformities in the lower trunk and thighs. Those who have more “apple-shaped” bodies tend to have fat collections in the upper and lower trunk regions.²¹ Surgical management of these patients must be individualized to address both the physical findings and individual concerns. For patients with localized adiposities, liposuction used to debulk fatty areas prior to skin excision can produce the best surgical results and greatest patient rehabilitation.

Weight loss patients who have achieved a body mass index below 30 tend to have fewer accumulations of remaining fat; for this group, hanging folds of skin in multiple body areas is the major problem requiring surgical intervention. A higher BMI is often accompanied by retained subcutaneous fat deposits that are resistant to weight loss. Many of those who undergo bariatric surgery are still obese when their weight loss stabilizes and they are ready for body contouring. Nonetheless, going from a BMI of 57 to 33 greatly improves health and function and changes lives for the better.

Table 1 briefly describes some of the body contouring procedures often performed after massive weight loss. Most of them involve removing redundant skin and tissue, then lifting and tightening. This is the purpose of the circumferential body lift, which addresses the full circumference of the lower trunk because the contour deformities of massive weight loss patients are circumferential, as seen in the patient shown in Figure 1. A few procedures, however, involve adding volume to areas that seem to “deflate” during weight loss such as the face, breasts, and buttocks. For the breasts and buttocks, the added volume comes from surrounding tissue that would otherwise be discarded as part of a nearby related procedure (see autologous gluteal and breast augmentation in Table 1). Using a tissue flap for augmentation simultaneously improves other deformities in the general area. The woman in Figure 3 had a type of breast deformity commonly seen in weight loss patients.

Table 1.

Body Contouring Procedures After Massive Weight Loss

Circumferential (Lower) Body Lift (CBL)	Considered the core procedure for body contouring because it removes a large amount of excess skin around the circumference of the lower trunk, including the flanks. Appearance is significantly improved, clothing fits much better, and physical functioning is easier. The procedure essentially combines an abdominoplasty, buttocks lift, and lateral thigh lift.
Panniculectomy	Removes only the pannus (lower portion of the anterior trunk) and therefore has a limited role in aesthetically improving the trunk, but it can help with performance of daily living activities and personal hygiene. It may be covered by insurance and can jump-start weight loss because it allows patient to exercise.
Liposuction	An essential adjunct to procedures that remove excess skin. Liposuction may be used to debulk areas with localized fat just prior to excision, or in preparation for later surgery. In patients who still have significant subcutaneous fat in multiple areas, large-volume liposuction alone is done first with excisions to follow later.
Mons Reduction	Ptosis and/or residual fat in the mons pubis area creates problems with hygiene and sexual function. Reducing the mons may be done with liposuction and/or excision. Often combined with a CBL or thigh lift.
Autologous Gluteal Augmentation	A flattened and “deflated” buttocks region is a common deformity following massive weight loss, and a CBL may exacerbate this problem as the inferior skin flap is pulled superiorly. A tissue flap recruited from the upper buttock can be mobilized and contoured to add gluteal volume during the lower body lift.
Medial Thigh Lift and Thighplasty	Hanging folds of skin tend to accumulate in the medial thigh area after massive weight loss. A medial thigh lift is usually combined with a CBL. To address redundant skin in the mid to lower thigh, a thighplasty requires a vertical excision in the inner thigh and is done as a staged procedure at a later surgery.
Mastopexy/Breast Reduction	Atrophy of the breast tissue with moderate to severe skin laxity is common in weight loss patients. The deformity often looks like a hanging, deflated skin envelope best addressed with a mastopexy. Hanging skin that contains excess subcutaneous tissue requires breast reduction.
Axilloplasty	Excess skin and adipose tissue is common in the axillary and chest wall area lateral to the breast. Recontouring of the axilla is usually combined with other regional procedures such as brachioplasty, mastopexy with augmentation or breast reduction, and back procedures.
Autologous Breast Augmentation	Some patients benefit from restoring breast volume in addition to excising hanging skin. Augmentation with autologous tissues recruited from the axilla and lateral chest wall to increase breast volume is a safe way to address multiple deformities.
Upper Torso	Multiple large skin folds or rolls that redrape across the back after massive weight loss are a difficult problem that may be addressed in different ways. Debulking liposuction of the back rolls followed by a skin excision procedure (such as a CBL) is a common treatment. A back lift with an incision across the back at the bra line can sometimes be used with or in place of a CBL. Another option is a torsoplasty, in which the incision extends vertically down the side of the torso like the side seam of a blouse.
Brachioplasty	Skin excess of the upper arm that hangs loosely and jiggles is often called a “bat-wing” deformity. Skin is removed through an incision that extends from the axilla toward the elbow.

Figure 1A, B, C.

This patient had a laparoscopic Roux-en-Y gastric bypass 19 months before these photos were taken. Her BMI went from 61 before bariatric surgery (378 lb) to 30 (186 lb) at the time of her first body contouring surgery. A Kocher incision for cholecystectomy is visible on the abdomen. Excess skin and subcutaneous tissue are pronounced and she has persistent intertrigo beneath the large pannus.

Figure 3.

The upper body is best approached as an aesthetic unit that encompasses upper arm, axilla, and breast. This 32-year-old went from a BMI of 46 to 25 after a laparoscopic Roux-en-Y gastric bypass 14 months before her preoperative photos.

Top A, B - The long and deflated-looking breasts are common with these patients as is the excess skin in the axilla and lateral chest areas. Breast tissue in these patients has the consistency of bread dough and is difficult to shape.

Bottom C, D - Postoperative photos (C, D) were taken 5 months after a brachioplasty, axilloplasty, and mastopexy, which raised the nipple-areolar complex superiorly. Some of the excess subcutaneous tissue lateral to the breast was used as a flap for autologous volume augmentation.

For many patients, including the one seen in Figure 1, multiple body contouring procedures may be combined in a single surgery.^9,10 Procedures are usually grouped according to body region (arms, breasts, lateral chest, etc.) or priorities (lower trunk and breasts). In most cases, the area of greatest concern to the patient is addressed first. Performing more than one excisional procedure generally depends on the patient’s health, current BMI, number of surgeons operating, and areas to be contoured. A circumferential body lift, for example, should not be combined with an extended thighplasty or torsoplasty because skin tightening in these procedures requires pulling the skin along different vectors of tension—from lateral to medial rather than inferior to superior.

In many cases, excisional procedures are done in one part of the body and debulking liposuction is done in another. Three or more months later, the areas that received liposuction will have the excess skin removed.

In massive weight loss patients, safety takes priority above all else. Body contouring after massive weight loss is not performed as outpatient surgery but it rather requires hospital admission for at least one night. As a general rule, this patient group has a long history of health problems and therefore requires close monitoring. Since a surgery involving multiple procedures may take anywhere from 4 to 8 hours, patients are at risk of metabolic and hemodynamic instability, blood loss, and difficulties with tissue perfusion due to microcirculatory damage caused by obesity. On the other hand, the number of surgeries a patient desires can be minimized if multiple procedures are performed in a single surgery. One way to balance competing interests is to have more than one surgeon operating so each can work on a different anatomic area simultaneously thereby reducing operative time, which increases safety and reduces costs. Combining procedures allows a patient to pay for the operating room time, anesthesia, anesthesiologist, and hospital admission one time rather than many. Even in cases that combine procedures, two or three staged operations may be necessary to address the many serious deformities that follow massive weight loss. ^8,9,22

Summary

The statistics on severe obesity and the increased popularity of bariatric solutions indicate that plastic surgeons will be seeing patients seeking extreme body contouring in increasing frequency. These patients come with complex medical, physical, and psychological issues that require a comprehensive treatment approach and analysis of deformities prior to re-contouring. Massive weight loss patients are more challenging but, at the same time, they tend to be the most gratifying to work with because body contouring dramatically changes their lives.

Many massive weight loss patients thought their problems would be over after they lost weight, but this is not necessarily the end of the story. For many patients, improving or restoring health by losing a significant amount of weight only begins the process of rehabilitation. Recovery from obesity will not be complete as long as its constant reminders remain. No amount of exercise and no available technology designed to tighten or firm will get rid of the hanging folds of excess skin and tissue. Surgery alone can do that. The full emotional rehabilitation for many of our patients comes only after body contouring, when they can finally see the results of their hard work, take pride in their appearance, and feel good about themselves.

Figure 1D, E, F.

Photographs taken two months after the patient’s third body contouring procedure. Her first surgery consisted of a circumferential body lift with mons reduction and gluteal autologous augmentation, brachioplasty, axilloplasty, and breast augmentation with silicone gel implants. Three months later she had a facelift. Her third surgery was performed five months later and consisted of a medial thighplasty and lateral mons reduction. The circumferential incision is nearly 11 months old and easily hidden by clothing. The patient began a walking program before body contouring. Now she runs a few miles per day or works out in a gym.

Figure 2.

Preoperative (top) and 11-month postoperative (bottom) views of results after brachioplasty to recontour the upper arms.

Biography

C. B. Boswell, MD, FACS, practices at BodyAesthetic Plastic Surgery & Skincare Center in St. Louis.

Contact:cbboswellmd@bodyaesthetic.com