Bariatric Times - February 2009 - (Page 12) 12 Practice Management Bariatric Times • February 2009 malabsorptive bariatric procedures and should be screened in perspective body contouring patients.18, 23 Patients should receive 1,200 to 1,500mg of calcium citrate in 800 IU of vitamin D per day31 to avoid deficiencies, which can lead to metabolic bone disease32 and a longterm risk of osteoporosis and fractures. Screening for deficiencies include evaluation of ionized calcium, 25-hydroxyvitamin D, alkaline phosphatase, and parathyroid hormone levels,33 as well as bone density studies when appropriate. SMOKING In addition to micronutrient and macronutrient assessment and supplementation, smoking and other tobacco products cause micro vascular vasoconstriction by way of the action of nicotine and its activation of the sympathetic nervous system.34 Cigarette smoke also contains carbonmonoxide, which contributes to tissue hypoxia by binding hemoglobin to form carboxyhemoglobin, which has a high affinity of oxygen and decreases the delivery of oxygen to peripheral tissues.35, 36 Patients who smoke or have a history of heavy smoking are at increased risk for fat necrosis, wound infection, flap necrosis, and respiratory complications following surgery.37, 38 Patients are advised to stop smoking at least four weeks prior to undergoing any body contouring surgery.39, 40 SUMMARY With the increased number of bariatric surgery procedures done in this country, body contouring surgery has reached a more diverse patient population requiring a variety of surgeries. Proper nutritional assessment and supplementation with a high biological protein and high-quality multivitamin, along with any specific nutrient deficiency, should be suffice in capturing the majority of nutrient deficiencies commonly experienced after bariatric surgery. It should be deemed a high priority to hopefully decrease morbidity and improve wound healing after body contouring surgery. lose massive amounts of weight leaving unwanted sagging skin around the torso and extremities, and have a need for body contouring surgical intervention. This section attempts to describe an approach to body reconstruction in the bariatric patient using a staged approach. Using three separate stages to approach the body contouring concerns in the bariatric patient allows all surgeries to be completed within three six-hour blocks. This limits the amount of anesthesia, reduces the risk of DVT, and prevents problems with nerve compression injuries.42 This approach also aids the patient in allowing the financial obligation to be spread out over a greater time period. DISCUSSION Any patients who have undergone bariatric surgery or massive weight loss through medical regimens have found that the inelasticity of their skin and the large amounts of excess skin are equally as distressing as what led them to undergo bariatric surgery in the first place.41 The face deflates, and the person may actually look more aged after massive weight loss. The arms have tremendous amounts of excess skin and it can be embarrassing to wear short-sleeve clothing. The breasts and chest wall sag and lose their volume. The abdominal wall is possibly the area that is affected the most, and skin can be found hanging over the pubic region and sometimes to the middle of the thighs.43 The thighs themselves can be tremendously disfigured and have large volumes of excess skin, which can be both a functional and cosmetic problem. In the end, the whole body appears to need an overhaul in order to improve the cosmetic, functional, and psychological aspects associated with massive weight loss. To help remedy these problems, our practice has devised the GBRx™ method for reconstructing the body. GBRx™ is a staged surgical approach to remove the unnecessary excess skin and provide a more contoured shape. The patients who undergo these procedures are usually at least 15 months out from their gastric bypass procedure and have plateaued with their weight loss. The “consult” usually starts in a support group-type setting with a question such as “Is there any way that exercising will tighten up the skin?” Ultimately the patient makes an appointment in the office to discuss his or her concerns in private and prioritize the approach; whether it be the abdomen, extremities, or face. The following is illustrative of the typical patient who undergoes GBRx™: During the first office consultation, the patient is given a PART 3: A STAGED APPROACH TO GASTRIC BYPASS RECONSTRUCTION (GBRX™) by MK Batra, MD, FACS; and RJ Nelson, BS, of Coastal Plastic Surgeons, Del Mar, CA BACKGROUND As the percentage of Americans who are obese continues to increase, the demand for bariatric procedures is steadily following this trend.41 Postoperatively, patients tend to http://www.robard.com
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.