M. Larsen 3; F. Polat 1; F. P. Stook 2; R. J. Oostenbroek 1; P. W. Plaisier 1; Hesp W. L.e.m. 1
Departments of Surgeray1 and Plastic Surgery2, Albert Schweitzer Hospital, Dordrecht, and
; Department of Plastic Surgery, Free University Medical Centre3, Amsterdam, The Netherlands
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 49, 4, 2007, pp. 95-98
surgery procedures have increased markedly, from 13,000 in 1998 to
a projected 100,000 in 2003 in the USA (8). With an increase in bariatric
surgery, more patients are presenting to complete their treatment course by
seeking removal of the surplus skin and soft tissue left after massive weight
loss. Body contouring is an important aspect to the overall treatment of the
morbidly obese patient (9). Quality of life improves after bariatric surgery
and is significantly enhanced after further body contouring, with improved body
image (4, 10). Bariatric surgery, as opposed to dietary or lifestyle changes or
pharmacologic interventions, offers sustained long-term weight reduction. After
massive weight loss, the pannus can interfere with clothing, physical activity
and hygiene, as well as be a cause for recurrent infection. There are,
therefore, clear advantages to excision of remaining excess tissue. In this
study, we retrospectively evaluated functional and aesthetic outcomes after
abdominoplasty following laparoscopic adjustible gastric banding (LAGB) and
correlated these to known preoperative risk factors. Specifically we aimed to
find whether this patient population was more susceptible to postoperative
complications than the general population seeking abdominal body contouring.
Also, our concern that this procedure has no long-term benefit in terms of BMI
reduction is investigated.
MATERIALS AND METHODS
study was conducted by chart review and a questionnaire (in Dutch) sent to
the 39 patients who had undergone LAGB and abdominoplasty (LAGB only, N=631) at
our hospital between 1995 and 2004. The LAGB and abdominoplasty procedures were
performed by the same surgeons, respectively. Patients who returned completed
questionnaires were included in the study. The questionnaire included the
following items: length, weight at present, weight before and after LAGB and
abdominoplasty, secondary corrective procedures, risk factors and comorbidities
(smoking, diabetes, arthrosis, alcohol consumption, sleep apnea, pyrosis,
depression, asthma, cardiovascular history, varicosis, panniculitis,
hypertension, hypercholesterolemia, age at onset of obesity), immediate and
late postoperative complaints, complications (infection, wound breakdown, deep
venous thrombosis, seroma, blood transfusion), satisfaction (change in hygiene,
mobility, general activity level), weight change after abdominoplasty (change
in operated or non-operated area and change in clothing size), and changes in
lifestyle (general activity level, diet, productivity, health level compared to
that before LAGB and before abdominoplasty). Finally patients were asked to
qualify their current appearance and their results in general, and to indicate
which procedures they would undergo again or advise to friends and family. All
open-ended questions were accompanied by a choice of answers (for example,
none, mild, moderate or severe discomfort postoperatively).
was performed only when stable weight loss after LAGB had occurred. In
practical terms, this meant a BMI as close to the ideal body weight as
possible, sustained over a period of three months. Patients were
instructed to cease smoking three months preoperatively. The abdominoplasty
technique was standard: removal of excess skin and subcutaneous tissue in an
ellipse from both iliac crests over the suprapuberal margin with undermining to
the costal margin and excision above the umbilicus. The latter was left intact
and sutured to the superior skin flap. Wounds were closed in three layers and
silicone drains left in the wound bed for 2–3 days. Complications such as
seromas, infections (requiring antibiotics), blood transfusions, wound
breakdown or re-exploration as well as the number of body contouring
procedures, weight gain or loss after abdominoplasty and general satisfaction
were noted from chart review. Statistical analysis was performed using JMP
statistical software (SAS Institute Inc., Cary, NC).
response rate to the questionnaire was 64%, thus 25 patients could be included,
with a mean age of 44 years and a median follow-up period after
abdominoplasty of 5.6 years. All patient demographics are noted in Tab. 1.
Noteworthy is that all patients were morbidly obese before LAGB (mean BMI: 47),
but still obese both before and after abdominoplasty (BMI 30 and 31,
respectively, range 24.9–39.3), despite 60% having undergone additional body
contouring procedures. Eleven patients (44%) experienced a form of
complication (Tab. 2). The only major complications were a wound breakdown
in two patients. The most frequent complication was seroma formation, occurring
in 25% of patients. Those who experienced a complication had
a slightly higher BMI (31.1) before abdominoplasty than patients who did
not (30.1), although this was not significant (ANOVA, p=0.53). Preoperative
risk factors encountered were smoking (28%), diabetes (4%), depression (40%),
varicose veins (24%), recurrent panniculitis (56%) and hypertension (20%). The
likelihood ratio ÷2 test found no statistical
relationship between any of these factors and the incidence of complications.
Two thirds of patients experienced some form of discomfort postoperatively
(mild, 24%; moderate, 36%; severe, 8%). In 44% the discomfort lasted for more
than one week. Most patients noted an improvement in personal hygiene (68%),
mobility (72%) and general functional capabilities (80%). Most also regained
weight after abdominoplasty (64%), ranging from <2.5 kg (8%),
2.5–5 kg (8%), 5–7 kg (8%), to >7 kg (29%). The same weight
was reported by 28%, and 44% lost weight after abdominoplasty: <2.5 kg
(12%), 2.5–5 kg (8%), 5–7 kg (4%), and >7 kg (20%). These
groups are not mutually exclusive, indicating fluctuations in post-contouring
BMI. Weight gain was reported in the secondarily treated areas by 44% of
patients, mostly in the abdomen. New areas of weight gain were seen by 24%.
Most of the secondary weight changes occurred after the first 6 months
post-abdominoplasty (56%). Clothing size changed in 84% post-abdominoplasty, in
all cases a reduction, by an average of 2.4 European sizes. In terms of
physical activity, the same level was kept by 52% and a higher level by
32%. Most patients (80%) did not alter their diet compared to
pre-abdominoplasty, while 12% reported an improvement in their diet.
Productivity at work was improved in 40% and reduced in 12%.
Post-abdominoplasty general health was better (44%), stayed the same (44%), or
was diminished (12%). The respective figures for post-LAGB are 96%, 0% and 4%. Physical
appearance was graded excellent (12%), very good (12%), good (36%), moderate
(28%) or bad (12%), while satisfaction with the general result was classified
as very satisfied (40%), satisfied (44%), not satisfied (12%) and very
unsatisfied (4%). Despite these outcomes, almost all patients would undergo the
procedures again (LAGB, 92%; abdominoplasty, 96%), and would recommend them to
family members (LAGB, 92%; abdominoplasty, 92%).
procedures lead to a significant improvement in quality of life, weight
reduction and marked decrease in comorbid conditions (2). The LAGB procedure is
the safest bariatric operation, with a 0.05% mortality rate, and carries
less risk of protein, vitamin, mineral or other nutrient deficiency (6). Potentially,
this will have an effect on wound healing after body contouring procedures,
although we do not have data from other bariatric procedures or from the
literature to verify this. In one study, no additional risk of postoperative
wound infection was found in patients undergoing different types of bariatric
surgery compared to obese patients undergoing general elective surgery
procedures of similar invasiveness (12). By contrast, wound complication rates
in obese patients undergoing abdominoplasty are more than doubled when compared
to non-obese patients, irrespective of any previous bariatric surgery (13).
General surgical procedures on obese patients also result in more complications
(5). A complication such as wound infection or dehiscence does not amount
to surgical failure, and abdominoplasty is a procedure with a high
success rate that provides adequate improvement to quality of life. However,
the post-bariatric surgery population is at increased risk for postoperative
complications, so that maximal reduction in BMI should be stressed to these
patients before undergoing abdominoplasty (1).
body contouring patients are challenging and require intensive follow-up (11).
Bariatric surgery and the subsequent weight loss require an additional 2–3 years
commitment towards body contouring procedures. There are proven psychological
benefits to post-weight loss body contouring. In a recent study, the body
image characteristics of post-bariatric surgery patients and those seeking
additional body contouring were compared (4). The post-bariatric group showed
a marked improvement in attitude towards body weight and shape, and
a normalization of the body image. However, the post-bariatric group
seeking additional surgery showed still compromised weight and shape attitudes
similar in scale to those of pre-bariatric patients. In these patients, after
cosmetic surgery, body image awareness and self-efficacy were improved, without
necessarily improving body satisfaction. We also found this difference in
improved self-efficacy versus largely unaffected body satisfaction in our
post-body contouring patients. Neither we nor other authors have been able to
explain this discrepancy. Interestingly, another study found that
a normalization of body image-related concerns occur in the face of most
patients remaining overweight or obese, suggesting that mediating factors may
be involved (3). This correlates well with our study population, as we found
the current mean BMI to be greater than that before abdominoplasty. No further
psychological evaluation was performed, however, and it would be interesting to
find whether despite improved body image, more dissatisfaction occurs with
other parts of the body in our population, as other authors have found recently
post-bariatric surgery population is at higher risk than the general population
seeking abdominoplasty, with morbidity ranging from 20% to 50% (1, 7, 11, 13).
We also found a complication rate (44%) within this range. The only
significant predictor for postoperative complications reported in the
literature is the pre-abdominoplasty BMI, with more than three times the risk
for patients with a BMI greater than 25 kg/m2 (1). We found
a similar trend in our population, although this was not significant.
A limitation to our
study is that it is retrospective and certain data such as intra- and
postoperative complications can be difficult to identify by medical record
review. The complication rate may therefore be underestimated. Another clear
drawback is that patient responses are subject to bias. Where LAGB is
a safe procedure with marked improvement in comorbidity and body image,
the results and complications from abdominoplasty after bariatric surgery may
be improved by an emphasis on optimal weight reduction preoperatively. Patients
should be told to expect a difference in body satisfaction
post-abdominoplasty than post-bariatric surgery, and be aware of that their
post-abdominoplasty BMI may not decrease in the long term.
Box 444, 3300 AK Dordrecht
1. Arthurs ZM., Cuadrado D., Sohn V., Wolcott K., Lesperance K., Carter P., Sebesta J. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am. J. Surg., 193, 2007, p. 567–570; discussion 70.
2. Champault A., Duwat O., Polliand C., Rizk N., Champault GG. Quality of life after laparoscopic gastric banding: Prospective study (152 cases) with a follow-up of 2 years. Surg. Laparosc. Endosc. Percutan. Tech., 16, 2006, p. 131–136.
3. Hrabosky JI., Masheb RM., White MA., Rothschild BS., Burke-Martindale CH., Grilo CM. A prospective study of body dissatisfaction and concerns in extremely obese gastric bypass patients: 6- and 12-month postoperative outcomes. Obes. Surg., 16, 2006, p. 1615–1621.
4. Pecori L., Serra Cervetti GG., Marinari GM., Migliori F., Adami GF. Attitudes of morbidly obese patients to weight loss and body image following bariatric surgery and body contouring. Obes. Surg., 17, 2007, p. 68–73.
5. Rogliani M., Silvi E., Labardi L., Maggiulli F., Cervelli V. Obese and nonobese patients: complications of abdominoplasty. Ann. Plast. Surg., 57, 2006, p. 336–338.
6. Salameh JR. Bariatric surgery: past and present. Am. J. Med. Sci., 331, 2006, p. 194–200.
7. Sanger C., David LR. Impact of significant weight loss on outcome of body-contouring surgery. Ann. Plast. Surg., 56, 2006, p. 9–13.
8. Santry HP., Gillen DL., Lauderdale DS. Trends in bariatric surgical procedures. JAMA, 294, 2005, p. 1909–1917.
9. Schechner SA., Jacobs JS., O’Loughlin KC. Plastic and reconstructive body contouring in the post-vertical banded gastroplasty patient: a retrospective review. Obes. Surg., 1, 1991, p. 413–417.
10. Song AY., Rubin JP., Thomas V., Dudas JR., Marra KG., Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring). 14, 2006, p. 1626–1636.
11. Taylor J., Shermak M. Body contouring following massive weight loss. Obes. Surg., 14, 2004, p. 1080–1085.
12. Topaloglu S., Avsar FM., Ozel H., Babacan M., Berkem H., Yildiz Y., Hengirmen S. Comparison of bariatric and non-bariatric elective operations in morbidly obese patients on the basis of wound infection. Obes. Surg., 15, 2005, p. 1271–1276.
13. Vastine VL., Morgan RF., Williams GS., Gampper TJ., Drake DB., Knox LK., Lin KY. Wound complications of abdominoplasty in obese patients. Ann. Plast. Surg., 42, 1999, p. 34–39.