Bariatric Times - February 2009 - (Page 15) Bariatric Times • February 2009 Practice Management Perspective individual stage. Foremost, a surgical team invested in body contouring for the massive weight loss patient is a prerequisite in order to get these multiple procedures completed in a six-hour time frame in a predictable fashion. In our practice, typically two surgeons or a surgeon and our physician assistant is involved at both stage one and stage two, while only one surgeon is required at stage three. Further, as any surgeon whose practice primarily takes care of reconstructive surgery for massive weight loss patients will tell you, there is always a degree of relapse of the skin with any of these procedures. There have been several patients who required further tightening of the arms at the second stage or the abdominal wall at the second stage. 15 The thighs are typically done through a vertical incision that starts in the groin crease and can extend all the way down to the knees. This appears to be the most effective way to get rid of all the excess skin and still leave a scar in an area, which is not obvious. Drains are placed along the chest wall, the lower back, and medial thighs. Once again, the stage is completed within a six-hour time frame, and the patient is sent to an overnight recovery facility. The following morning, the patient is assisted in getting out of bed and walking and is typically discharged to home. The thighs are perhaps the most difficult recovery for patients in that there is a higher incidence of forming seromas lymphoceles (small pockets of fluid) and prolonged swelling.45, 47, 48 I often implement lymphatic drainage postoperative in order to allow the swelling to dissipate faster. GBRX™ STAGE 3 The third, and usually the final stage, addresses the aging and deflation of the face. At this stage, a facelift, neck lift, brow lift, and upper and lower blepharoplasty is planned. This procedure typically takes 5.5 to 6 hours and perhaps has the most dramatic impact on the patients’ sense of wellbeing and their overall psychological outcome. Once again, an overnight stay is required not so much for pain control, but to monitor for any bleeding from the facelift procedure overnight. Contrary to popular belief, facelifts are not very painful procedures and this is perhaps the easiest recovery for the patient.46 While the majority of patients undergo GBRx™ stage 1, about 50 percent will go on to inquire about the next stage and this can be undertaken as early as six weeks depending on their recovery. Only about 20 percent of the patients in our practice will go on to have all three stages. This may be a reflection of the financial implications as well as their selfimage. Insurance unfortunately does not see these as reconstructive procedures rather as cosmetic procedures. We, however, always submit the procedures for insurance coverage along with photographs. The only procedures covered on a regular basis are the panniculectomies. The patient then pays for any additional work that may be done at the same time. In descending order, the most common areas to be addressed are abdomen, breast and chest, arms, thighs, back and buttocks, and face and neck. The GBRx™ staged approach limits not only the amount of recovery in the hospital for the patient, but also the financial obligations due to multiple procedures being performed at each COMPLICATIONS AND CONCLUSIONS Our practice has employed these reconstructive options in more than 200 patients at this time without a single incidence of deep venous thrombosis, and only one patient requiring blood transfusion after a GBRx™ surgery. There has been approximately a 10-percent incident of seroma of the abdomen, and 13-percent incident of seromas of the thighs. Overall, our patients’ satisfaction rate has been extremely high and more than 87 percent of our patients have reported that they have been either very satisfied or extremely satisfied http://www.bariatrictimes.com
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