Bariatric Times - January 2009 - (Page 29)

Bariatric Times • January 2009 Body Contouring Perspective 29 plication of the rectus muscles. Panniculectomy can be performed in anyone able to withstand general anesthesia as no undermining is done and the surgical time is relatively short. Rather, the recommendation applies to more advanced surgical techniques of abdominoplasty and lower body lift. Patients with a BMI between 32 and 35 are considered for contouring procedures on an individual basis, but those with a BMI greater than 35 are limited to panniculectomy as there is a dramatic increase in complications in this population.2 Nutrition. Protein is an essential building block for wound healing, and deficiencies result in an increased risk of wound breakdown. A simple, cheap way to assess for protein adequacy is by taking a dietary history of protein intake. If a deficiency is suspected, serum albumin, pre-albumin, and transferrin may be measured. A history is also taken to assess for vitamin and mineral deficiencies known to occur following bariatric surgery and patient compliance with supplements. Routine levels of vitamin A, vitamin C, and zinc are typically not measured; however, as essential components of wound healing, their deficiencies could contribute to wound healing problems. American Society of Anesthesiologists (ASA) classification. The ASA classification is a scheme anesthesiologists use as an imprecise guide to a patient’s overall health and a predictor for surgical and anesthetic risk. Patients who are to undergo lengthy contouring procedures should be an ASA class I or II.3 Nicotine cessation. Among contraindications to contouring procedures, active smoking tops the list. Smoking leads to increased skin necrosis and wound breakdown following abdominoplasty, and it is a significant risk factor for any contouring procedure. TECHNIQUES Many terms are used to describe techniques utilized by plastic surgeons to remove skin excess in different areas of the body, and a brief description of some of the more commonly used terms is prudent. Several of the following techniques have been designed specifically for post-bariatric patients to address their unique anatomy. Panniculectomy. This technique describes excision of a wedge of skin and fat in the abdomen with no undermining, plication, or liposuction. This procedure is often covered by insurance companies to improve safety reasons, plastic surgeons often prefer that the patient’s BMI is 32 or less to be considered for contouring regardless of the starting BMI.1 This recommendation does not apply to patients considering panniculectomy only, which is defined as removal of skin and fat of the abdomen without undermining of abdominal flaps or function and quality of life in postbariatric patients by alleviating rashes, improving ability to exercise, decreasing back pain, and improving sexual function. Abdominoplasty. Like panniculectomy, an abdominoplasty removes excess skin and fat of the abdomen. In addition, wide undermining is undertaken in order to maximize the amount of skin removed and the rectus muscles are plicated in the midline to narrow the waist. It is sometimes combined with flank or hip liposuction to improve results. Caution should be exercised when combining abdominoplasty with liposuction as this can potentially threaten the blood supply if performed improperly and lead to skin necrosis. Lower body lift/belt lipectomy. A lower body lift is particularly suited for the massive weight loss patient whose skin excess involves the anterior abdomen, lateral thighs, and posterior buttocks.4 The anterior incision is continued posteriorly so that a circumferential wedge of skin and fat is removed. Belt lipectomy is another term for this technique and differs only in scar placement.5 In patients who have lost excessive fat in their buttock region from the bariatric surgery, some skin and fat that would otherwise have been discarded is retained and shifted into the buttock region as “gluteal autoaugmentation” flaps based on the superior gluteal artery.6 Breast reduction/reduction mammaplasty. In obese patients prior to massive weight loss, the breasts are often protuberant and heavy. Breast reduction can alleviate some of the discomfort and pain experienced by these women and the procedure is routinely covered by insurance. With massive weight loss, the volume of the breasts often dramatically decreases, so it is uncommon for a woman to have enough excess breast tissue to qualify for breast reduction. Mastopexy (breast lift). The most common breast procedure for post-bariatric patients is a breast lift, or mastopexy. In this technique, the breast is reshaped and the nipple placed more centrally on the breast mound. If extra volume in the breast is desired, skin and fat from the axillary roll and mid-back region can be transferred to the breast as a flap based on the intercostal artery perforators (Spiral or ICAP flap— Figure 2).7, 8 This technique has the added advantage of removal of the undesirable excess tissue under the arm. Gynecomastia correction. Male gynecomastia following weight loss is commonly characterized by inelastic, droopy skin of the chest with localized fatty deposits. Men are reluctant to take their shirts off and expose the deformity. Traditional gynecomastia correction with liposuction and a periareolar incision is typically not enough to correct the large amount of extra skin on the chest. Instead, correction involves a combination of A lower body lift is particularly suited for the massive weight loss patient whose skin excess involves the anterior abdomen, lateral thighs, and posterior buttocks.4 liposuction and surgical excision, leaving a horizontal scar along the inferior border of the chest or extending medial and lateral from the nipple in a “boomerang” configuration. Brachioplasty (arm lift). The upper arm deformity is a common cause of concern and dissatisfaction in post-bariatric patients. The excess skin and fat in this region is readily exposed with tank tops or

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Bariatric Times - January 2009 Surgical Perspective Psychological Perspective Metabolic Perspective Editorial Message Table of Contents Editorial Board Anesthesiology Perspective Body Contouring Perspective Journal Watch Advertiser Index News & Trends

Bariatric Times - January 2009

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