What is Post Massive Weight Loss Surgery?
The following information has been prepared to familiarize you with facts regarding a variety of surgical procedures that are utilized to tighten excessively loose skin, frequently after massive weight loss. A smaller group of patients, who are normal weight and have never been overweight, will present with loose enough skin to warrant surgical tightening in the inner arm, posterior trunk, buttocks or thigh regions. If you fall into the post massive weight loss category, you are first to be congratulated for loosing so much weight!
Study after study has demonstrated the benefits of weight loss in patients who are morbidly obese. Your heart and lungs will not have to work as hard. Your legs will have less weight to carry. If you had adult onset diabetes, it will surely have improved or even gone away after the weight loss. Unfortunately, as you have found, skin does not go back to its pre-stretched condition. Most patients who loose a large quantity of weight desire to have the excess remaining skin from their abdomens removed and their breasts uplifted, with or without an implant, or reduced. The tummy tuck and breast recontouring procedures are covered in separate sections entitled abdominoplasty and breast reduction/uplift. Post weight loss patients also frequently are left with loose neck skin or jowls, and these procedures are covered in the face lift section. This section will focus on procedures utilized to address skin laxity along the inner arms, upper and mid back regions, buttocks and thighs.
Twenty five years ago, it was rare to have a patient walk into a plastic surgeon’s office after substantial weight loss. But these days, we routinely see patients who have lost in excess of one hundred pounds. About three quarters of the massive weight loss patients we see did so with the assistance of bariatric surgery – such procedures have been designed to either decrease the size of the stomach pouch or some variety of “bypass” which shunts food down the intestines quicker without absorbing as many calories. With the advent of laproscopic surgery and the more sophisticated bypass and stapling techniques, the efficacy, safety and popularity of such “bariatric” surgery has sky rocketed. This year over 140,000 bariatric procedures will be performed in the United States, and the numbers keep climbing higher each year as more centers with expertise in such procedures open up. But a good quarter of the weight loss patients we see achieved their results the good old fashioned way, by altering their diets and by exercising regularly!
The areas which we can address with plastic surgery are the neck and face, breasts, inner arms, abdomen and back of trunk, hips, thighs and buttocks. As mentioned above, facial skin tightening, breast surgery and a straight forward abdominoplasty are covered elsewhere. Here, we will focus on procedures designed to improve the inner arms, posterior trunk, hips, thighs and buttocks.
In all of these areas, the problem is an excessive amount of skin. It must be stressed that some skin laxity in these areas is absolutely normal. Every patient over the age of 20 will have some skin laxity in these areas, and the only time they should be addressed surgically is if the amount of skin laxity is much more than average, and if the degree of correction to be achieved can be justified by the resultant scarring. Procedures such as liposuction, rhinoplasty, breast augmentation, eyelid surgery and a face lift most frequently do not leave any visible scars. Body contouring procedures, on the other hand, ALWAYS leave a long and wide scar – each patient will have to decide for themselves if the improvement in the skin laxity will be justified by the resultant scars, cost and risks of surgery.
An inner arm brachioplasty is an operation in which excess skin and fat from the inner arm, between the axilla (arm pit) and elbow, is removed and the remaining skin tightened. This is accomplished by excising a large ellipse of this excess skin. The resultant scar will run along the inner arm, hidden with your arm down along your side but definitely visible if a patient is wearing a short sleeve shirt and has their hands up in the air!
The posterior trunk can contain excess rolls of skin either continuing around the back at the level of the breast or lower down as a continuation of the abdominal skin rolls. The upper back excess can be excised by removing wedges and leaving the final scar at the level of a brassiere in a female. The lower trunk is usually addressed in conjunction with an abdominoplasty and is called a “belt lipectomy”. Such belt lipectomies result in a tightening of the abdominal wall and the lower posterior trunk, including the hip/thigh area and upper buttocks. The incision follows the fold along the lower abdomen, above the pubis, and continues on the backside just above the buttocks. Such scars, while noticeable when unclothed, are usually easily hidden within standard shorts. It is important to understand that during such procedures, a transverse wedge of tissue will be removed and the patient will experience a vertical tightening of the skin – if you pinch your abdomen or lower back vertically, a very significant tightening will be appreciated, but if one pinched horizontally, no appreciable tightening will be noted.
The lower buttocks and thighs can be tightened in a similar fashion, with the resultant scar location to be determined by the areas of your most significant skin excess. As with the belt lipectomy or abdominoplasty, the skin tightening will usually occur in one plane, usually vertically, and not result in significant horizontal tightening. If massive skin laxity is present, both a horizontal and a vertical tightening might be desirable. In such situations, a “T” shaped scar may be designed with a transverse incision along the upper inner thigh, perhaps extending obliquely onto the buttocks, as well as a vertical scar down the inner thighs towards or to the inner knees.
Most patients who have lost a lot of weight have multiple areas to address. These body contouring procedures can be combined to address multiple areas, with certain limitations and exceptions. It is not safe to address the inner thighs and abdomen at the same sitting because of blood flow interruption to the pubis and strip of skin between the inner thighplasty scars and abdominoplasty or belt lipectomy scars. But with either procedure, it would be safe to address, for example, the inner arms or breasts. Such procedures may also be combined with non-skin tightening operations such as liposuction, eyelid surgery or other procedures. Your overall health and age will also help determine how much surgery you can tolerate in one day. But even if you are in perfect health, it is unwise to electively schedule procedures that are designed to be longer than six hours in length because after that time, your chance of developing a blood clot in your calved or other complications will become more likely.
The operation is directed toward an improvement and will not in any way give you complete obliteration of all folds, laxity and stretch marks. You must accept the judgment of your plastic surgeon and realize that he will remove as much as is safe and suitable. Particularly in patients with thicker fatty layers or marked skin excess, it may be desirable to return for additional skin excisions to obtain an optimal result. Should this prove desirable, the patient will be responsible for all costs associated with all secondary surgical procedures.
The type of skin, degree of elasticity and age of the patient all influence the overall result that is obtained. The operation should not be undertaken if the patient’s weight is not stable or if a patient has not made a commitment to themselves to keep the weight off in the foreseeable future. While it is not necessary for the patient to reach a certain weight before surgery may be performed, it is desirable that the patient’s weight be stable for at least six months prior to surgery and that the patient be at a weight he/she feels can be maintained after the procedure.
A common question is, “How long will the results of this procedure last?” This is impossible to state. Factors affecting the length of the result include age at the time of operation, physical conditioning afterwards, type of skin, and alterations in weight. In general, it is not necessary to repeat these procedures after an optimal result has been achieved. Should the patient wish to repeat the operation, regardless of the length of time since the initial operation, the degree of laxity or fatty excess remaining, each patient will be responsible for the cost of a subsequent procedure.
Post Massive Weight Loss Surgery Overview Video
You are requested to read this information thoroughly and to discuss any questions which might arise with your surgeon before you give your consent to proceed with this procedure. You are also requested to keep this form as a reference in the postoperative period.
Preoperative instructions
You may visit your surgeon as many times as you wish, to have all of your questions answered. At your final preoperative visit, your final questions will be answered and you will confirm that you understood the procedure to be performed, that this material has been explained to you, that you have read and understood these information sheets, and that you accept the risks by signing the informed consent forms. You will be given prescriptions for surgical soap that will be used before surgery, as well as for pain pills and antibiotics, along with instructions for their use. Certain laboratory tests will also be required within two weeks of surgery. If you are over the age of 50, you will have to obtain a cardiogram. You may have blood drawn by our office nurse during your final preoperative visit, or, if you prefer, at your family doctor’s office or any state licensed laboratory (i.e. Kaiser Hospital, etc.). All patients will be asked to stop smoking at least a month prior to surgery in an effort to maximize your body’s ability to heal the incisions following the operation.
It will be necessary to scrub the surgical sites for ten minutes the evening prior to surgery and a final time the morning of surgery before leaving home. Washing the surgical site these two times with Hibiclens soap will lower the possibility of an infection occurring after surgery.
As with all other elective procedures, the patient should avoid Ibuprofen (Advil), all aspirin products and excessive quantities of Vitamin E (the small amount contained in most multivitamin preparations is not harmful) for two weeks before surgery, as these inhibit the clotting mechanism and increase your chances of unnecessary operative bleeding. A separate list of other medications, which can potentially affect clotting capabilities, will be discussed along with your preoperative instructions.
Ordinarily, your anesthesiologist will call you the night before surgery to discuss the anesthetic care plan with you. But if you miss the call or your anesthesiologist does not call you, do not worry as you will be able to discuss your anesthesia and have all your questions answered in the morning, at the Surgery Center, prior to your procedure. You must make arrangements to have someone drive you to and from the Surgery Center and stay with you at home for the first two or three days afterwards.
Details of the procedure
The operation will be performed in an outpatient facility under general anesthesia.
The incisions will be made as discussed with you preoperatively, and the excess skin and fat will be trimmed. Sometimes, your surgeon may be required to extend the incisions or place them in a different location than discussed preoperatively. This may become desirable if, in the surgeon’s opinion, such diversions from the operative plan will improve the final result. On occasion, it may be appropriate to suction some of the excess fat that can not be resected, but there is a limit to how much can be removed without jeopardizing the viability of the skin flaps. Rubber drains are frequently inserted prior to suturing the wound closed; these drains will be removed later in the office after the drainage has decreased to less than 30 cc. (one ounce) of fluid per day. This usually takes about a week to ten days but can take up to a month or even longer. In addition, small catheters which infuse local anesthesia into the surgical field may be inserted – these are usually removed 2-4 days after surgery. The pain pump catheters will reduce the discomfort normally associated with such procedures.
Post-operative care
Adequate pain medication will also be prescribed. All patients, who go home on the day of surgery or the next morning, will find that an assistant at home is a necessity for the first three days or so. High bulk foods are highly encouraged and laxatives may be necessary to prevent straining associated with constipation.
The patient will be encouraged to walk as much as possible at home after surgery as this will reduce the possibility of pneumonia or of clots forming in your calf veins. It will be necessary to avoid flexing the hips after thigh or buttocks procedures for the first few weeks to prevent excess tension on the suture lines.
The patient will usually be allowed to shower after the drains have been removed, but soaking in a bathtub is to be avoided for two weeks. Wounds are generally closed with buried sutures. The incisions are covered with surgical tapes, which are to stay in place for the first two weeks. These tapes will not fall off with gentle showering as long as you refrain from rubbing them with face cloths or towels.
Your first post-operative visit will generally be scheduled two to four days after surgery at which time the pain pump catheters will be removed, or four to six days later if you choose not to have the pain pumps. The drainage tubes will be removed at a subsequent visit, when the drainage has essentially stopped. You will be required to have someone drive you to the office for your first, and perhaps second, visits. Most patients find that they can gradually increase their activity levels thereafter. You may drive a car with caution, wearing a safety belt, beginning 48 hours after your last pain pill or sedative, if you feel comfortable and physically able to do so.
Possible complications
Serious complications after an abdominoplasty are relatively uncommon. However, there will be a long scar (usually, but not always, within the bathing suit line) extending from hip to hip. The scar may remain itchy, painful, thick, or otherwise unsightly. It is unusual, but possible, for areas of fat to liquefy and drain through the incision for many months. As with any abdominal procedure, it is also possible for a suture or staple to become infected and to erode through the skin years later.
Fat is poorly vascularized, does not have much tensile strength and does not contribute significantly to holding the wound together. In this type of surgery, particularly involving the trunk or lower extremities, there is a very high incidence of portions of the incisions pulling open. Occasionally the wound margins can be resutured, but frequently the safest course of action is to leave the wound open and allow it to heal by contraction and secondary intention. This might take a few months to occur and may necessitate wound care at home from a visiting nurse. Should this occur, it may be necessary to perform a secondary scar revision a year or so later. As with all complications or desired secondary procedures, each patient will be responsible for the cost of a subsequent care or procedures.
It is common to experience swelling of the hands with a brachioplasty, or of the ankles following thigh or buttocks surgery. Such swelling is self limiting. Some areas of numbness will be evident following body contouring surgery. Usually, most of the feeling will return within about a year but some patients will experience areas of permanent numbness.
One of the most common problems after body contouring is a persistent collection of serous fluid under your skin after the drains have been removed. Should this occur, this fluid will be aspirated by your surgeon with a needle during your post-operative visits. Such drainage always stops eventually (but may persist for more than a month) and usually does not affect the final results. If wound problems develop, it may take several weeks or even months for healing to take place, and the patient will be required to wear dressings over the open wound. Because of the extensive skin and fat undermining, areas of skin may die and slough, or even require surgical debridement or a skin graft. Rarely, phlebitis may develop in leg veins and even more rarely, blood clots could travel to the lungs, potentially leading to a fatal complication.
Perfect symmetry does not exist before or after body contouring surgery. Scars will never be identical from side to side. As mentioned earlier, it will take longer than a year for scars to fade.
Secondary procedures may occasionally be desirable to revise scars or to remove additional tissues. The patient will be responsible for all costs associated with secondary surgical procedures.
It is not possible to list every conceivable complication. As with any operation, there could be potential complications, which could even be fatal. The foregoing is not intended to frighten or upset you but to enable you to make your decision with an understanding of some of the involved risks.
Fees and financing
If a significant spreading of the anterior muscles or a hernia is present, your insurance company may, rarely, reimburse you for a portion of the Surgery Center bill and of the professional fees. But the focus is on the word rarely! Insurance companies do not pay for the skin tightening during body contouring or other purely cosmetic portions, regardless of how much weight you have lost, how unsightly the remaining skin folds are, or even if the skin folds interfere with normal function. If there is reason to believe that your insurance company might help you pay for abdominal muscle tightening, the office staff will provide you with the necessary information to submit to your insurance carrier.
All fees are due prior to the surgical procedure and, if any portion of your procedure will be covered by your carrier, you will be reimbursed directly by your insurance company. In compliance with suggestions adopted by the American Society of Plastic Surgeons, it is customary for the patient to pay all fees for cosmetic surgery prior to the desired operation. This insures that the patient is sincere in his/her motivation and can afford the surgery, thus creating a better patient/physician relationship. A non-refundable deposit will be required to secure your desired surgery date. The remainder of the fees must be paid prior to the surgery, no later than the time of the preoperative visit, one week before surgery. Additional fees are also required for laboratory tests, surgical facility fees, the anesthesiologist, and if necessary, mammography. If additional surgical procedures become necessary, additional facility, laboratory, anesthesia, implant costs and professional fees will be incurred. The surgical facility and anesthesiologist fees quoted will be based on our best faith estimate; the final fee may vary as these fees are based on surgical time, and it is not always possible to predict exactly how long a procedure will take to complete. It is important that you understand that the patient is responsible for all costs associated with all secondary surgical procedures or for the treatment of any complications that may arise as a result of this elective surgery.
I, _________________________________________________certify that I have read and understand the “Body Contouring – Post Massive Weight Loss Reconstruction” information sheets dated March 2008, that my surgeon has answered all of my questions to my satisfaction, that I understand and accept the risks associated with surgery, and that I give my informed consent for this (these) procedure(s).
Witness_______________________________ Date__________________
Initial if copy requested/given to patient____________________________
Copy placed in chart __________________________________________
Copyright 11/87 Last revised 03/08
Juris Bunkis, M.D., F.A.C.S.
How long should I wait until I can go out socially?
Social activity should be limited while the patient is uncomfortable. Lifting anything that causes discomfort should be limited for approximately four to six weeks to allow the tissues to heal properly. Strenuous activity should be avoided during the initial six to eight weeks. Basically, most patients find that they can return to normal activity as the discomfort of the operation fades away. Office work can usually be resumed within 1-2 weeks of surgery, but the patient should expect a six-week delay before returning to physical labor or strenuous exercise. It will take longer than a year for scars to fade and the abdomen to feel relatively normal. The lower abdominal skin may feel numb forever and completely normal feeling is not to be expected.
