Abstract
Background
The current study examined a range of body image concerns and associated distress and impairment in patients who have undergone bariatric surgery and are seeking subsequent body contouring surgery.
Objectives
The aim of this study was to investigate the hypotheses that individuals seeking body contouring endorse a broad pattern of body image concerns and that overall body image concern is associated with greater impairment and disability.
Methods
The participants were 56 adults seeking body contouring surgery after bariatric surgery. All participants completed a self-report questionnaire designed for the present study to assess body image concerns specific to patients who have undergone bariatric surgery and a battery of established measures of disability, impairment, and eating-disorder psychopathology.
Results
The most commonly endorsed concerns were related to loose skin (body dissatisfaction, feeling embarrassed in public, and skin rashes) whereas the least endorsed items included concerns related to scars from bariatric surgery (body dissatisfaction, avoidance of social situations, and difficulty concentrating). Participants endorsed a broad pattern of frequent distress and impairment related to physical body image changes post–bariatric surgery. Greater body image concerns were associated significantly with higher levels of disability, work-related impairment, and eating-disorder psychopathology.
Conclusions
Patients seeking body contouring surgery reported a range of body image concerns with significant associated distress, disability, and impairment related to physical changes post–bariatric surgery. The present findings underscore that although bariatric surgery is effective for reducing weight and metabolic disturbances, additional interventions for addressing body image concerns that are frequently distressing and impairing may be needed.
Poor body image is common in patients seeking bariatric surgery; 1 in 5 patients identified appearance concerns as the primary motivator for seeking surgery.1,2 Although there is evidence to suggest body dissatisfaction reduces significantly following bariatric surgery,3-10 the existing literature on body image improvements after bariatric surgery is equivocal, suggesting the relation is complex.2,11-13 Research has demonstrated that “body image” is best understood as being comprised of a number of related, albeit distinct, constructs reflecting various cognitive, affective, and perceptual aspects,14 and that the different constructs may be both differentially related to other aspects of functioning and patient groups15 and may respond differently to interventions including bariatric surgery.4,5 For example, some studies have reported significant improvements in some specific body image domains but not in other domains,5,16-19 whereas others have not found significant improvements in body image following bariatric surgery.20 Lacerda et al found that despite significant weight loss, the majority of participants post–bariatric surgery reported continued perceptual inaccuracies about the size of their bodies as well as overall dissatisfaction with the postsurgical results.18 Some research also suggests that certain subgroups of patients, such as those with disordered eating behaviors (eg, “loss-of-control” eating) following bariatric surgeries, may also struggle with heightened body image concerns.21
It may be unsurprising that the relation between bariatric outcomes and body image is complex because patients who undergo bariatric surgery experience extreme physical changes, both internal and external. Whereas some physical changes, such as weight loss, are desired22 and likely anticipated, other changes, such as excess skin, may be less anticipated by patients. Previous research has suggested excess skin postsurgery is both very common and problematic,23 and is linked to other physical sequelae such as dermatitis,24 itching,24 and irritation in skin folds,23 as well as difficulty exercising,24 intimate relationship distress,25 and high levels of daily impairment.23 However, there is a dearth of research examining other physical changes postsurgery and the subsequent impact of these physical changes on body image and associated functioning.
Perhaps another indicator of post–bariatric surgery body dissatisfaction is that a high percentage of patients desire or elect to undergo body contouring surgery (BCS) following their surgery.24,26,27 As many as 89.9% of patients desire subsequent BCS following bariatric surgery,27 with greater percentages for women than men, 75% vs 68%, respectively.24 BCS is costly28 and has a higher risk of complications in a postbariatric population.29 Therefore, it is important to understand the role of body image in influencing the distress and impairment felt by patients seeking BCS following bariatric surgery.
The present study sought to provide a nuanced and detailed examination of body image concerns occurring in the post–bariatric surgery period. The purpose of the present study was twofold: (1) to examine the frequency of specific body image concerns and associated distress and impairment in patients seeking BCS post–bariatric surgery; and (2) to examine the relation between body image concerns and other impairment indices including work productivity and impairment in daily activities. Individuals seeking body contouring were hypothesized to experience a multitude of physical changes as relevant to their body image and would report high frequencies of distress and impairment, particularly in domains related to excess skin. Lastly, the endorsement of greater body image concerns was hypothesized to be related to greater disability and impairment in other life domains.
METHODS
Participants
Participants were 56 adults seeking a consultation for BCS following bariatric surgery. Participants were recruited by direct surgeon referrals or flyers placed at plastic surgery centers or sent directly to individuals’ electronic chart file if they had opted into research at the study institution and had a history of bariatric surgery. Inclusion criteria included ages 18 and older and a history of bariatric surgery. All data collection was completed in the northeast United States. Data were collected between August 2016 and May 2019. This investigation received approval from the Yale University Institutional Review Board and all participants provided written informed consent.
Participants ranged in age from 26 to 67 years with a mean age of 45.2 [SD = 11.7] years. Most were female (n = 52, 92.9% female; n = 4, 7.1% male). The ethnic/racial composition self-reported was as follows: White or Caucasian (n = 35, 63.6%), Black or African American (n = 10, 17.9%), Native Hawaiian or Pacific Islander (n = 1, 1.8%), mixed race (n = 1, 1.8%), and other (n = 8, 14.5%). Twelve participants (21.4%) identified as Hispanic/Latinx. The majority of participants identified as heterosexual (n = 52, 92.9%; n = 3, 5.4% other; n = 1, 1.8% gay/lesbian); relationship status was reported as: married (n = 24, 42.9%), single (n = 21, 37.5%), divorced (n = 8. 14.2%), widowed (n = 2, 3.6%), and cohabitating (n = 1, 1.8%). The majority of participants reported working full time (n = 35, 62.5%) followed by unemployed/not working outside the home (n = 14, 25.0%), and working part-time (n = 7, 12.5%). Self-reported educational attainment was as follows: some college (n = 12, 21.4%), graduate/professional degree (n = 12, 21.4%), college degree (n = 10, 17.9%), associates degree (n = 8, 14.3%), high school diploma (n = 8, 14.3%), general education diploma (n = 3, 5.4%), some graduate/professional education (n = 2, 3.6%), and some high school (n = 1, 1.8%).
Of the 56 participants, 64.3% (n = 36) had undergone a sleeve gastrectomy, 32.1% (n = 18) a Roux-en-Y gastric bypass, and 3.6% (n = 2) adjustable banding. Average self-reported presurgical body mass index (BMI) was 47.6 [SD = 8.5] kg/m2 (range 36.1-71.8 kg/m2) and average current BMI was 30.1 [SD = 5.4] kg/m2 (range, 21.5-51.0 kg/m2). Average total percentage weight loss since bariatric surgery was 36% [SD = 9.0%] (range, 12.2%-54.9%). Time since bariatric surgery ranged from 7 to 185 months (mean, 39.5 [SD = 39.6] months).
Protocol
Participants were asked to complete a survey battery consisting of self-report measures. Surveys were emailed or mailed to participants based on their preference. Compensation for completion of the survey battery was a $20 Amazon (Seattle, WA, USA) gift card.
Measures
Yale Program for Obesity, Weight, and Eating Research—Bariatric Body Image Scale
The Yale Program for Obesity, Weight, and Eating Research—Bariatric Body Image Scale (YP-BBIS; Appendix, available online at www.aestheticsurgeryjournal.com) was developed for the present study to assess body image concerns of individuals who have undergone bariatric surgery, and includes a focus on distress and impairment related to these concerns. Items were developed based on clinical observations by a team of clinical experts with extensive experience with body image across diverse patient groups14,15 and specifically with patients seeking and undergoing bariatric surgery4,5 and the available empirical literature.12 Specific concerns focused on issues related to loose/excess skin after bariatric surgery, scars from bariatric surgery, and other appearance-based issues such as hair loss after bariatric surgery. Of note, no other bariatric body image measures assess hair loss and other life domains impacted by loose/excess skin and bariatric surgical scars.30,31 A total of 17 questions were used with Likert-type responses ranging from “Never” (0) to “Almost always or always” (3) for all items. Each question had 3 parts. The first part of the question assessed the extent to which a body image concern occurred. Participants answered the second 2 parts only if endorsement of the first item occurred. The second part asked about the degree of distress associated with the body image concern, and the third part asked about the degree of impairment in day-to-day functioning due to the body image concern (eg, 9. During the past month … I was dissatisfied with my body because of loose skin. 9a. If yes: My dissatisfaction with my body because of loose skin made me feel upset or distressed. 9b. My dissatisfaction with my body because of loose skin negatively impacted my daily activities [or day-to-day life]). Participants who reported “Never” to the first part of each item skipped to the first part of the next item, thereby skipping the second (distress) and third (impairment) parts of that specific item. Higher scores indicated greater body image concerns. Cronbach’s α = 0.90 for the total score (first part of items 1-17).
World Health Organization Disability Assessment Schedule 2.0
The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)32 is a 36-item, self-report measure that assesses disability across multiple domains of daily life due to health conditions. Items are rated on a 5-point Likert scale ranging from 0 (“None”) to 5 (“Extreme or cannot do”). Total weighted impairment is calculated from an item response theory worksheet. Additionally, average scores across domains are calculated with greater scores indicating greater impairment. Domains include: (1) Understanding and communicating (α = 0.88); (2) Getting around (α = 0.91); (3) Self-care (α = 0.82); (4) Getting along with people (α = 0.87); (5) Life activities—household (α = 0.96) and Life activities—school/work (α = 0.91); and (6) Participation in society (α = 0.92). In the current sample, the total Cronbach’s α was 0.97.
Work Productivity and Activity Impairment Questionnaire: Specific Health Problem
The Work Productivity and Activity Impairment Questionnaire: Specific Health Problem (WPAI:SHP)33 is a 6-item questionnaire examining impact of a specific health problem on work productivity, including time lost from work (subscale: absenteeism), reduced productivity at work (subscale: presenteeism), productivity loss, and reduced productivity while engaged in regular activities (subscale: regular activity productivity loss) in the past week. In the present study, the specific health problem provided to participants was weight. Greater scores indicate greater impairment. Cronbach’s α was not calculated because the answers are not expected to be consistent.
Eating Disorder Examination-Questionnaire 7-Item Brief Version
The Eating Disorder Examination-Questionnaire 7-Item Brief Version (EDE-Q-7)34 was used to assess disordered-eating behaviors and attitudes. The EDE-Q-7 has consistently been found to be psychometrically superior to the original longer version and has reliably demonstrated a well-fitting factor structure in nonclinical34 and clinical samples,35,36 including patients undergoing bariatric surgery.37,38 Items are rated on a 7-point Likert scale ranging from 0 (“No days” or “Not at all”) to 6 (“Every day or markedly”). All items are summed for a global score; higher scores indicate greater eating-disorder psychopathology. Additionally, select items are summed to calculate 3 subscales: (1) Restraint (α = 0.86); (2) Dissatisfaction with weight/shape (α = 0.82); and (3) Overvaluation of weight/shape (α = 0.95). In the current sample, Cronbach’s α for the global score was 0.84.
Statistical Analysis
Analyses were conducted with SPSS version 26 (IBM Corp., Armonk, NY). Baseline means and standard deviations were calculated for demographic variables. YP-BBIS body image concerns were categorized based on the presence/absence of endorsement, distress, and impairment and frequencies were calculated. Additional relations between experiences of bariatric body image concerns (YP-BBIS) and measures of disability (WHODAS), work productivity (WPAI:SHP), and disordered eating behaviors and attitudes (EDE-Q) were examined with Pearson’s correlations. Cohen’s 1988 interpretative guidelines were used: 0.20 (small), 0.40 (medium), and 0.80 (large).39
RESULTS
Table 1 summarizes the frequency (percentage) of participants who endorsed each specific item of body image concern. For each item that an individual endorsed, they were also asked to rate their level of associated distress and impairment specifically related to that body image concern. Broadly, an examination of the percentages suggests that participants endorsed both a multitude of physical changes as relevant to their body image and endorsed high rates of subsequent distress and impairment. The 3 most frequently endorsed items included concerns related to loose skin. The majority (n = 52; 92.9%) reported body dissatisfaction because of loose skin. Additionally, 83.9% (n = 47) reported feeling embarrassed in public because of loose skin and 78.6% (n = 44) reported experiencing skin rashes due to loose skin. In contrast, the 3 least frequently endorsed items included concerns related to scars from bariatric surgery. Nearly 20% (n = 11; 19.6%) reported body dissatisfaction due to scars from bariatric surgery. Similarly, 16.1% (n = 9) reported avoiding public or social situations because of bariatric surgery scars, and 10.7% (n = 6) endorsed difficulty concentrating on tasks or getting things done because of scars from bariatric surgery. Notably, when an item was endorsed, associated distress and impairments in daily functioning were also commonly reported to be present.
Table 1.
Frequency (%) of Participants Who Endorsed Each Body Image Concern and Associated Distress and Impairment
| During the past month … | Endorsed % (n) | Distressed % (n) | Impaired % (n) |
|---|---|---|---|
| I lost hair or my hair thinned | 76.8 (43) | 83.7 (36) | 51.2 (22) |
| “… because of loose skin” | |||
| I was dissatisfied with my body. | 92.9 (52) | 94.2 (49) | 71.2 (37) |
| I was embarrassed in public | 83.9 (47) | 95.7 (45) | 74.5 (35) |
| I had skin rashes | 78.6 (44) | 100.0 (44) | 75.0 (33) |
| I had difficulty fitting into clothes or findings clothes that fit | 76.8 (43) | 93.0 (40) | 65.1 (28) |
| I was embarrassed in front of my partner (significant other or spouse) | 75.0 (42) | 95.2 (40) | 73.8 (31) |
| I criticized or thought negatively about myself as a person | 67.9 (38) | 92.1 (35) | 68.4 (26) |
| I had difficulty exercising | 51.8 (29) | 100.0 (29) | 72.4 (21) |
| I avoided being in public or social situations | 51.8 (29) | 96.6 (28) | 82.8 (24) |
| I had skin infections in addition to rashes | 44.6 (25) | 96.0 (24) | 80.0 (20) |
| I had difficulty concentrating on tasks or getting things done | 30.4 (17) | 94.1 (16) | 88.2 (15) |
| “… because of scars from bariatric surgery” | |||
| I criticized or thought negatively about myself as a person | 23.2 (13) | 76.9 (10) | 61.5 (8) |
| I was embarrassed in front of my partner | 21.4 (12) | 83.3 (10) | 58.3 (7) |
| I was embarrassed in public | 19.6 (11) | 63.6 (7) | 63.6 (7) |
| I was dissatisfied with my body | 19.6 (11) | 90.9 (10) | 72.7 (8) |
| I avoided being in public or social situations | 16.1 (9) | 88.9 (8) | 88.9 (8) |
| I had difficulty concentrating on tasks or getting things done | 10.7 (6) | 100.0 (6) | 100.0 (6) |
Valid percentages used.
Table 2 shows correlations between body image concerns and various domains of distress and impairment, as well as disordered-eating behaviors and attitudes. Greater body image concern (total YP-BBIS score) was associated significantly with greater presurgical BMI, greater percentage total weight loss, greater disability (total WHODAS score), greater disability in the areas of understanding and communicating, self-care, getting along with others, household activities, school/work activities, and participation in society, and domains of impairment at work, including greater presenteeism, increased productivity loss, and greater regular activity productivity loss. Greater overall body image concern (YP-BBIS) was associated significantly with greater eating-disorder psychopathology (global EDE-Q scores) as well as with the 2 EDE-Q body image subscales: dissatisfaction with shape/weight and overvaluation of weight/shape.
Table 2.
Post–Bariatric Surgery: Body Image Scale Correlations
| Body image total score | |
|---|---|
| Age | –0.01 |
| Presurgical BMI | 0.32* |
| Current BMI | 0.10 |
| Weight loss (%) | 0.32* |
| Months since bariatric surgery | 0.17 |
| Disability (WHODAS) | |
| Understanding and communicating | 0.36** |
| Getting around | 0.25 |
| Self-care | 0.30* |
| Getting along with others | 0.52*** |
| Life activities—household | 0.42*** |
| Life activities—school/work | 0.43*** |
| Participation in society | 0.70*** |
| Total impairment (%) | 0.52*** |
| Work productivity/impairment (WPAI:SHP) | |
| Absenteeism (% work time missed) | –0.02 |
| Presenteeism (% impairment while working) | 0.64*** |
| Productivity loss (% overall work impairment) | 0.43** |
| Regular activity productivity loss (% impairment) | 0.58*** |
| Eating-disorder psychopathology (EDE-Q) | |
| Global score | 0.40** |
| Restraint | 0.09 |
| Dissatisfaction | 0.41** |
| Overvaluation | 0.56*** |
BMI, Body Mass Index; EDE-Q, Eating Disorder Examination-Questionnaire; WHODAS, World Health Organization Disability Assessment Scale; WPAI:SHP, Work Productivity and Activity Impairment Scale: Specific Health Problem. Significance: *P < 0.05, **P < 0.01, ***P < 0.001.
DISCUSSION
This study of individuals seeking BCS after bariatric surgery examined a range of body image concerns specifically relevant to potential physical changes after bariatric surgery. Participants reported a multitude of body image concerns impacting various life domains (eg, relationships, being in public, exercise) as well as associated distress and impairment in day-to-day functioning due to these body image concerns. Overall, body image concerns due to loose skin were more common than body image concerns due to bariatric surgery scars, although a sizable subgroup endorsed body image concerns related to bariatric surgery scars. The most commonly endorsed body image concerns included body dissatisfaction, embarrassment in public, and skin rashes all due to loose skin, as well as hair loss or thinning following bariatric surgery. Of note, when a body image concern was endorsed, distress and impairments in day-to-day functioning due to the concern were also quite common.
Analyses revealed a consistent pattern that greater body image concerns were associated with greater disability overall, as well as greater disability across multiple life domains, including participation in society, life activities, getting along with others, and greater work impairment. Results revealed a pattern in which greater physical changes (eg, hair loss, skin rashes, skin infections) were associated significantly with less participation in society and greater activity impairment and overall impairment. Greater body-dissatisfaction scores were also associated with a greater percentage of body weight loss and greater eating-disorder psychopathology. Notably, the finding that greater weight loss was associated with worse body image might be attributed to loose skin concerns following weight loss
The findings of the present study replicate previous literature that examined general concerns related to loose skin and rashes23,24 and extend the literature by examining a range of additional body image concerns related to loose skin, bariatric surgery scars, and other appearance-related issues such as hair loss/thinning following bariatric surgery, as well as the reported distress and impairment associated with these body image concerns. For instance, one of the novel findings includes the percentage of participants reporting hair loss/thinning (76.8%) that is both distressing (83.7%) and impairs day-to-day activities (51.2%). Further, this seems to be the first study which examined body image concerns due to surgical scars from bariatric surgery. The findings suggest that for individuals who have undergone bariatric surgery, the medical complications (eg, rashes, infections) are as equally distressing and impairing as the psychological complications of surgery.
Collectively, the present findings also extend the previous literature2 both by providing greater specificity about the specific focus/target of the body image concerns and by documenting their substantial negative impacts correlated with physical changes post–bariatric surgery. The current study provides a more nuanced perspective on body image post–bariatric surgery; whereas much of the previous literature suggests that many aspects of body image improve following bariatric surgery,3-9 this study highlights the importance of finer-tuned assessment of specific aspects of body image concerns experienced following bariatric surgery. Although some aspects of body image concerns do improve postsurgery, others, such as excess skin or concerns about hair loss, become salient and, if present, can be distressing and impairing.
Given the broad pattern of specific postsurgical body image concerns endorsed, it is possible that the frequently used measures of body dissatisfaction developed for other patient groups (ie, not post-bariatric) may not effectively capture current body image concerns experienced by patients following bariatric surgery. For example, in the present study, the 3 most commonly endorsed body image concerns would not be captured on a standard measure of body image such as the EDE-Q, and yet were correlated with the EDE-Q total score and 2 subscales. Additionally, body image concerns rated as distressing and impairing would not be captured on commonly used measures of body image concerns in post–bariatric surgery groups either. For example, although the Excess Skin Survey40 provides a comprehensive assessment of concerns about specific areas of the body impacted by excess skin, no concerns beyond excess skin are examined. Further, other existing measures such as the BODY-Q scales,31 although more comprehensive in scope, assess concerns about specific domains of appearance and quality of life separately, making it difficult to distinguish whether certain body image concerns are more distressing or impairing than others. The findings of the present study highlight the complexity of body image, particularly in this sample for whom physical changes are both substantial and occurred rapidly. The results of the present study underscore the need for measure specificity; if body image concerns of patients following bariatric surgery are significantly different to those prior to surgery, it is crucial that measurement tools properly capture these differences.
Understanding the interrelation between body image concerns, distress, disability, and impairment post–bariatric surgery is crucial for this population. Given the high levels of distress and impairment associated with a range of body image concerns following bariatric surgery, the present findings highlight the potential need for further interventions postsurgery. One potential intervention is BCS. Current research suggests that the majority of individuals who receive BCS following bariatric surgery are pleased with the surgical outcomes; 11,13 however, BCS is cost-prohibitive and often not covered by insurance11 despite evidence that it can improve quality of life and physical functioning.41 Additionally, there are limitations to the impact of BCS; research has found BCS to improve certain aspects of body image, such as appearance evaluation, but not others, such as fitness and health evaluation and orientation.41 This underscores the potential need for psychological intervention postsurgery. For example, interventions targeting body image specifically have shown success in reducing shape and weight concerns for both males and females.42 However, research is needed to determine whether these interventions would also be effective for individuals following bariatric surgery or BCS. Future research should investigate the design and implementation of an intervention targeting body image and its impacts on alleviating impairment. The present research may also have additional implications for pre–bariatric surgery interventions. More specifically, previous research has highlighted the importance of managing expectations surrounding weight loss for patients in the presurgical process and its impact on body dissatisfaction.43 Given the wide range of body image concerns found in the present study, it may be important for expectation management to also include what patients should expect about bodily changes broadly in addition to weight loss.
Conclusions from the current research should be considered alongside its limitations. First, this study was cross-sectional with a small sample size. The cross-sectional design precludes any speculation about temporal associations or changes over time. Future research with larger samples should examine changes across different facets of body image as time postsurgery elapses. Second, although the use of a specially designed measure was warranted in order to answer the current research question, the psychometric properties of the YP-BBIS are unknown. Future research should examine the use of the YP-BBIS measure in larger and more diverse samples to establish the reliability and validity of the measure. Nonetheless, this measure provided a helpful descriptive summary of specific concerns and associated impairment. Additionally, replicating the current study in a larger sample would allow for the comparison of outcomes across groups to assess whether there are any relevant differences across racial/ethnic groups or genders. The current sample was primarily female, which limits the ability to examine gender-specific findings and limits the generalizability of the findings to groups of other gender composition. Further, although body image concerns about surgical scars were assessed, participants were not asked whether their surgery was a laparoscopic procedure, which is designed to minimize scarring. This precluded drawing any conclusions about whether the type of procedure influenced overall concerns about surgical scars. Importantly, however, average time since surgery was 3.29 years, suggesting that the majority of individuals likely had laparoscopic surgeries. Also worth noting is the limited ability to draw temporal conclusions. Participants varied greatly in their time since bariatric surgery, limiting the ability to ascertain whether the reported body image concerns are reflective of a certain period post–bariatric surgery. Future research should examine how body image concerns change over time following bariatric surgery and subsequent treatment-seeking for BCS. Lastly, the sample in the present study is a group of individuals seeking BCS. Although some previous research has found no significant differences in body satisfaction between individuals with and without desires to seek BCS after bariatric surgery,44 it is still possible the present sample reflects individuals more highly distressed or impaired by body image concerns. Although it is important to understand the concerns of this subset of patients who have received bariatric surgery, particularly as they are seeking out further surgical intervention, future research should also examine similarly diverse facets of body image concerns in patients not interested in BCS after bariatric surgery.
CONCLUSIONS
The present study provided additional support for multifaceted body image concerns following bariatric surgery, including excess skin, while also identifying some novel concerns, such as hair loss/thinning and concern about bariatric surgery scars. The results suggest that in addition to high rates of body dissatisfaction, a strikingly high rate of patients seeking BCS after bariatric surgery are also endorsing substantial distress, disability, and impairment related to bodily changes post–bariatric surgery. The present findings underscore that although bariatric surgery may be an effective tool for weight loss for patients, additional interventions for improving body image or overcoming weight-related disability and impairment may be needed. Further research and intervention efforts directed towards individuals following bariatric surgery are both warranted and necessary.
Supplementary Material
Disclosures
Dr Bennett has received honoraria for lectures, Dr Ivezaj has received honoraria for journal editorial roles and lectures, and Dr Grilo has received grants from the National Institutes of Health (Bethesda, MD, USA), honoraria for CME lectures, and book royalties from Guilford Press (New York, NY, USA) and Taylor & Francis Publishing (Milton Park, Abingdon, UK).
Funding
This research was supported by a grant from the Aesthetic Surgery Education and Research Foundation (ASERF). Drs Grilo and Ivezaj were also supported, in part, by NIH grants R01 DK098492 and R01 DK126637. The sponsor had no involvement in the study design, collection, analysis, or the decision to submit the report for publication.
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