There is much knowledge to share between bariatric surgery and plastic surgery, which are close fields. There are also some misunderstandings, and a need to improve cooperation between them.
Plastic surgery can play a very important part relative to massive weight loss. It is already well known that fat pads can be removed either by aesthetic or plastic surgery. More recently, surgeons have been exploring methods of plastic reconstruction after massive weight-loss, such as that obtained after digestive surgery. Bariatric surgeons should be aware that some of their patients will need heavy and painful reconstructive procedures.
1. Key-points of the strategy in plastic surgery in an obese patient with massive weight-loss:
Successful weight-loss can be associated with two types of side-effects:
- The skin is too loose: The tension and elasticity of the skin vary greatly from one person to another. A 25 kg weight-loss can be as troublesome as a 80 kg one, depending on the patient.
The quality of the skin will also vary on different parts of the body. Many patients find the abdomen to be their major area of concern, although the arms, the interior side of the thighs, or breasts can be just as troublesome.
- Fat is still present in some areas of the body: This depends on the type of obesity (gynoid or android). The goal of plastic surgery is to re-harmonize the two parts of the body by removing excess fat and skin.
2. Therapeutic strategy
a. Scheduling the operation :
There is a general consensus for scheduling the operation when the weight has stabilized and remained so for several months. As a rule, one counts at least one year after digestive surgery (or the successful outcome of an intensive diet).
Notwithstanding, some patients are prepared to have surgery when they still have few kilograms to lose. This is not necessary a contra-indication, for the following reasons:
b. Where to start?
One should start with the most troublesome area, which in most cases is the abdomen.
Some patients prefer to start with a breast reduction because postoperative care is short, enabling them to return to work rapidly. For some, even if upset by a hanging abdomen, reshaping their face is a priority because of its obviousness.
3. Parts of the body on which to have plastic surgery
a. Abdomen : Abdominoplasty is the most claimed operation (80%).
It aims at the following:
1. To remove excess fat tissue.
2. To remove excess skin above and beneath the umbilicus.
3. To repair overdistended muscles resulting from pregnancy or the pressure formerly exerted by body fat before weight loss.
The scar resulting from the abdominoplasty is situated very low, just above the pubis, going up slightly on either side, and can be hidden in the swimsuit. The pubic hair is repositioned as normal.
An additional liposuction may also decrease the size of the "Venus mount".
Follow-up is generally simple. Hospitalisation lasts about one week. The main complications patients face are thrombo-embolism, and wound problems. The patient should remain off work for one month.
Both functions of the breasts, i.e. feeding and erotic, are important. The psychological role they play according to their shape is major, and any flaw in their shape or size can cause much distress. From of health point of view, they may cause lumbago if too heavy. Hence, the aim of surgery is to recreate a normal shape and volume. The procedure is relatively straightforward: a hospitalisation of 48 to 72 hours is enough.
The only cause for concern is the scars left behind after surgery, but these are getting smaller and smaller thanks to rapidly improving techniques.
c. Inside part of the thighs :
This is one of the areas of the body where skin is the thinnest. As the patient loses weight, the skin shrinks, creating a distressing roll of fat, which in turn leads to functional and aesthetic problems ("it rubs").
Surgery is effective (1,5 kg of skin is removed from each thigh) and discreet because the scar can be hidden at the root of the thigh.
Scar healing does, however, take longer than usual because the scar is located in a fold which is very mobile and is also prone to steep.
d. Bodylift :
This is a complete lift of the lower body, with a scar going right round the body, low enough to be hidden by the swimsuit.
A bodylift is often performed in conjunction with liposuction of the fat on the buttocks.
The bodylift is a relatively heavy procedure because of the amount of skin removed (20 to 30 cm in height of skin around the body), the weight of the tissues (4 to 6 kg in an average, sometimes more), the length of the intervention (4 to 5 hours). Also the fact that the abdomen, buttocks, hips, and thighs are all lifted at the same time adds to the seriousness of this intervention. The recovery period is often marked by extreme fatigue but the result can be very spectacular.
The excess of fat and skin on the arms can be a problem with clothing. Lifting of the arms is therefore very sought.
The operation itself is relatively straightforward, and the scar is easily hidden under the arm. This operation can, for example, be combined with a breast reduction.
f. Face :
The aim is to give the face a firm and fresh contour. The colour of the skin may temporarily change after the operation, and the patient may experience a feeling of tingling and hardening of the skin on the face and the neck. Healing is slow, and it can take weeks or even months before the final result is obtained.
The scars can be hidden within the hair, and by appropriate make-up. The skin remains fragile for several weeks. It is therefore recommended to avoid exposure to the sun and to protect the skin with a total sunblock cream. The patient may use make-up very soon after surgery.
We would like to emphasize three points:
1. A previous laparoscopic approach for bariatric surgery (such as the adjustable gastric banding) facilitates further plastic surgery. But let us not forget that the patient will hence deserve the best possible reconstruction.
2. Although we know the main rules of timing and priorities for reconstruction , such topics should be investigated furthermore.
3. Coordination between the two surgical fields should be upgraded, so that we could reach an integrated approach for each patient. This has been the goal of common meetings, such as those organized in Lyon in 1999 and 2000 in November.