Bariatric Times - January 2009 - (Page 30)

30 Body Contouring Perspective FIGURE 1. Post-bariatric body deformity. This patient lost over 100 pounds and complained of excess skin of her arms, abdomen, flank, and thighs. Her breasts lost a significant amount of volume and her nipples have descended. safety practices and are summarized as follows.10 Intraoperative hypothermia is a concern with long procedures and exposure of large surface areas. Therefore, prewarming with forced air heating blankets and warming the tumescent and intravenous fluid may help avoid drops in central core temperature.11 Particular attention is also paid to padding pressure points and changes from supine to prone position to avoid inadvertent iatrogenic injuries. A reverse Trendelenburg slant can help avoid the increase in intraocular pressure sometimes observed with prolonged prone positioning.12 The incidence of thromboembolic events is dramatically increased with body contouring procedures and no consensus currently exists on prophylactic thromboembolism prevention. Most surgeons agree that mechanical prevention with pneumatic compression devices should be initiated for all patients and chemoprophylaxis should be strongly considered for these patients.10 Routine practices for preoperative antibiotics and prevention of seroma with drains or quilting sutures are also followed. One final question that often arises is the feasibility of performing more that one procedure in one operative setting. This can be advantageous for the patient in planning for time off work, arranging for postoperative help, and saving money. This question is typically answered on a case-bycase basis according to the patient’s anatomy and current weight as well as the length of time he or she is able to take off work. The answers may also vary from surgeon to surgeon depending upon the amount of assistance in the operating room and the surgeon’s comfort level with the procedures. Since blood loss can be significant when multiple procedures are combined, I typically ask my patients to auto-donate two units of blood 2 to 4 weeks before surgery if they are having three or more procedures in the same operative setting. The blood is given back to the patient in the latter half of the operation. In my experience, this dramatically enhances the patient’s recovery. Together, the patient and surgeon can work together to devise a plan that makes sense for both and is safe. Bariatric Times • January 2009 multidisciplinary team that currently cares for these patients. REFERENCES 1. 2. Panel R. Body contouring after massive weight loss. Plast Reconstr Surg. 2006;117(Supplement 1). Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007;193(5):567–570; discussion 570. Rohrich RJ, Gosman AA, Conrad MH, Coleman J. Simplifying circumferential body contouring: the central body lift evolution. Plast Reconstr Surg. 2006;118(2):525–535; discussion 536–528. Pascal JF, Le Louarn C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223–230. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential truncal excess: the University of Iowa experience. Plast Reconstr Surg. 2003;111(1):398–413. Colwell AS, Borud LJ. Autologous gluteal augmentation after massive weight loss: aesthetic analysis and role of the superior gluteal artery perforator flap. Plast Reconstr Surg. 2007;119(1):345–356. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006;56(5):481–486; discussion 486. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap. Ann Plast Surg. 2006;57(4):361–365. Hurwitz DJ, Holland SW. The L brachioplasty: an innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest. Plast Reconstr Surg. 2006;117(2):403–411; discussion 412–403. Colwell AS, Borud LJ. Optimization of patient safety in post-bariatric body contouring: A current review. J Aesthetic Surg. 2008;28(4):437–442. 3. 4. 5. 6. 7. 8. 9. 10. FIGURE 2. Mastopexy with the ICAP flap. This patient desired a breast lift and an increase in volume (left). The excess skin and fat of the axillary roll was utilitzed to enlarge the breasts at the time of the lift (right). FIGURE 3. Arm deformity following massive weight loss. Preoperative photos of the arm are characterized by excess skin and fat of the upper arm (left). Following brachioplasty, the contour is improved but a scar remains running along the inner aspect of the arm and extending onto the chest wall (right). short sleeve shirts in warmer weather. Brachioplasty techniques remove this excess skin and fat in the upper arm and chest wall.9 Unfortunately, our ability to correct the contour deformity comes at the cost of a scar running on the inner surface of the upper arm (Figure 3). For most patients, the tradeoff is worthwhile and the scar is hidden with the arms placed at the side. Vertical thigh lift. The thigh deformity consists of excess tissue extending from the groin to the knee. The original crescent thigh lift technique is not sufficient to correct the massive weight loss deformity. Like the brachioplasty technique, contour correction of the vertical thigh comes at the expense of a scar running along the inner medial thigh. Intraoperative hypothermia is a concern with long procedures and exposure of large surface areas. 11. Zhao J, Luo AL, Xu L, Huang YG. Forced-air warming and fluid warming minimize core hypothermia during abdominal surgery. Chin Med Sci J. 2005;20(4):261–264. Ozcan MS, Praetel C, Bhatti MT, et al. The effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables. Anesth Analg. 2004;99(4):1152–1158. 12. PATIENT SAFETY In contrast to the typical healthy patient seeking elective plastic surgery, post-bariatric body contouring patients are more complex and have more reported complications.5 It is therefore prudent as a specialty that an effort be made to optimize safety in this population, and specific articles have been written to review best SUMMARY Post-bariatric body contouring is a new, exciting specialty in plastic surgery that can maximize the results obtained from weight loss surgery. It is increasingly recognized as an important component for total care of the post-bariatric patient, and the plastic surgeon may soon become part of the standard AUTHOR CORRESPONDENCE Amy S. Colwell, MD, Division of Plastic Surgery, Mass General Hospital, 15 Parkman Street, WACC 435, Boston, MA 02114; Phone: 617643-5963; Fax: 617-643-5964; E-mail: acolwell@partners.org.

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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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