INTRODUCTION
Ongoing Treatment
Plastic surgeons are treating a growing number of patients after massive weight loss. This is likely due to the prevalence of obesity in America and greater public awareness of this problem and the health consequences. Bariatric surgery has gained popularity.
After successfully losing a great deal of weight, people are disappointed to find that the skin does not contract as much as they would like, leaving folds of redundant skin. The face, neck, arms, breasts, trunk, thighs, and knees may all be affected. The breasts deflate. The buttocks appear flattened.
Patients learn that now that they have lost the weight, there is a whole new set of issues to deal with. Because loose skin is a major problem, they need excisional techniques that leave long scars. And because so many areas are affected, they usually require more than one operation. Patients accept the trade-off of scars for getting rid of loose folds of skin, which are more embarrassing than scars.
The results are never quite as good as the surgeon would like, because of the compromised skin tone. Touch-ups are to be expected. Because numerous procedures are done, the chance of having a complication is high. Counting delayed wound healing, seromas and asymmetry, the likelihood of a patient encountering some type of complication approaches 100%!
Sometimes insurance pays for bariatric surgery, because of the medical problems associated with obesity. However, insurance dose not typically pay for treatment of the skin deformities that result from massive weight loss. For patients that just paid for their bariatric surgery (typically a gastric sleeve or gastric bypass), the thought of paying much more for their plastic surgery can be disappointing.
A trusting patient-physician relationship is key, along with the understanding that treatment will be ongoing over a period of months to years. With proper education, patient satisfaction is often very high, and the results can indeed be life-changing.
PHOTOS OF FEMALE PATIENTS
A.B., Age 31
Procedure: Lower body lift, liposuction of abdomen, flanks, and inner thighs.
Height: 5’3″
Before Weight: 162
BMI: 28.7
Before, 3 months after
A.J., Age 36
Height: 5’6″
Before Weight: 185
BMI: 29.4
Procedure: Abdominoplasty and liposuction of abdomen, flanks, inner thighs , arms, and axillae.
Before, 3½ weeks after
S.S.,
Age 42
Height: 5’5″
Before Weight: 191
After Weight: 190
Procedure: First combined procedure: Lower body lift, liposuction of inner thighs, knees, and medial calves. Second combined procedure: Breast augmentation and lift, liposuction of arms, brachioplasties, and inner thigh lifts.
Before, 2 months after
Before, 2 months after
R.W., Age 45
Procedure: First combined procedure: Inner and outer thigh lifts, brachioplasties, liposuction of thighs, knees, arms and flanks.
Second combined procedure: Abdominoplasty, liposuction of abdomen.
Third combined procedure: Breast augmentation and lift, secondary outer thigh and buttock lifts, secondary inner thigh lifts, liposuction of outer thighs and knees.
Before, 7 years after first and second procedure, and 1 month after third procedure
M.M.
Age: 50
Height: 5’7”
Weight: 182 lbs.
First procedure: Lower body lift, inner thigh lifts, liposuction of abdomen and flanks, and buttock fat injection.
Second procedure (6 months later): Breast reduction plus implants, brachioplasties, revision of abdominoplasty, and additional liposuction of abdomen and flanks, plus arms and axillae, and inner thighs.
Before, 6 months after second procedure.
S.S., Age 52
Procedure: Lower body lift, inner thigh lift, buttock fat injection, liposuction of the abdomen, flanks, outer thighs, and knees.
Before, 4 months after
PHOTOS OF MALE PATIENTS
K.K., Age 37
Height: 6’0″
Before Weight: 189
Procedure: Lower body lift (abdominoplasty plus outer thigh and buttock lift), liposuction of
abdomen, flanks, and breasts.
Before, 5 months after
H.B., Age 61
Procedure: Abdominoplasty plus inner thigh lifts
Height: 6’0″
Before Weight: 264
After Weight: 258
Before, 5 months after
The Patient’s Priorities
The major issues are discussed at the first consultation. A “battle plan” is developed. It is usually best to treat the patient’s priorities first. An abdominoplasty is usually the first order of business. This is done with simultaneous liposuction. If the outer thighs and buttocks are saggy, a lower body lift is recommended, which is a tummy tuck and outer thigh/buttock lift done at the same time. Sometimes an inner thigh lift is done as well, either at the first operation or a subsequent one. It is more common today to use a longitudinal incision down the inseam of the inner thigh, rather than an incision in the groin crease, to remove the greatest amount of excess skin and get the best result. The buttocks often appear flat after major weight loss. Fat injection is commonly used to help fill out the buttocks.
Procedures—Breast Lift Brachioplastiesfacelift
The operative sequence is individualized according to the patient’s priorities. Most patients wish to get as much accomplished in one operation as is feasible. This is understandable. The surgeon needs to maximize efficiency to get as much done as possible while avoiding overly lengthy surgery or excessive blood loss. Only plastic surgeons who are very proficient in these procedures done individually should undertake combinations.
Surgery after massive weight loss is often a combination of procedures—breast lift (often with implants), abdominoplasty, thigh and buttock lift, brachioplasty, and liposuction.
The reader is directed to these sections to learn more about what to expect after surgery.
Surgery to treat deformities from major weight loss is a major undertaking. This is why it is typically done in stages. There is a saying in surgery, “major surgery = major complications.” Some surgeons have reported complication rates as high as 100%. Indeed, it depends on how you define a complication. Seromas are relatively common because large areas are often undermined, particularly when done with an abdominoplasty. Complications include infection, delayed wound healing, scar deformities, asymmetry, and contour deformities. The skin deformity is such that perfection is not possible. However, these patients are grateful for the improvement, and tend to value correction of the loose skin over scarring. Touch-up procedures are common and should be expected.
- Avoid straightening your hips fully. Walk in a stooped position to reduce tension on the abdomen.
- You can take stairs, but with assistance.
- At night, be sure to keep your hips flexed and sleep on your back (“supine”), not on your side. A recliner works. Otherwise, use several pillows under your upper body and tuck one under your knees.
- The suction drain needs to be emptied when it is about one-third to one-half full. After emptying, be sure to squeeze the bulb when closing the valve. The bulb should stay collapsed. This indicates that it is creating the suction needed to draw fluid off the abdomen. Don’t be surprised if you have to empty it several times the night after surgery. This is normal. Although it looks like a lot of blood is coming out, it is mainly fluid (not much blood is needed to turn the fluid red). The drainage typically slows down after the first 24 hours.
- You should be getting up to urinate every 3 hours or so. Be sure to drink adequately to stay well hydrated. These trips to the bathroom are also helpful to get you up and moving. This helps prevent blood clots from developing in your legs.
- Your tummy will feel very tight. This is normal.
- Sometimes there is some blood-tinged drainage around the drain tube. Simply tuck some gauze in to absorb it and confirm that the suction drain is working. Be sure there are no kinks in the tubing and the bulb is collapsed.
- You can unzip the garment (if you are wearing a girdle) partly at the top if it is digging in to your sides. If the garment is uncomfortably tight in the inner thighs, you can cut the margin to relieve any uncomfortable constriction. Similarly, if the garment is too tight at the knees, it can be cut to release any tourniquet effect, although this is rarely necessary.
- Some bloody drainage into the dressing and through to the garment is normal after surgery. However, if this increases, or if the dressing becomes saturated, notify the office.
- You will be seen the day after surgery in the office. The dressing will be removed. When you go home you can bathe later that day, or at the latest, the next day. It is okay for the tummy to get wet. Just put the drain over the edge of the bathtub or hold it in the shower.
- Be careful when you take off the garment. You may feel light-headed at first. It is best to take off the garment and then sit for several minutes before standing. This allows your body time to adjust to the new position. If you feel faint when standing, immediately lie down, even if this means lying down on the bathroom floor. Much better to lie down than fall down. The lightheadedness will go away. Don’t try to fight the faint feeling. Give in and lie down. This is typically important the first few days after surgery. Later on, this is usually not a problem.
- Keep a layer of gauze between the drain tube and the skin when you have the garment on. This will avoid an indentation which could possibly leave a mark.
- Sometimes the tightness of the abdomen can cause heartburn. An antacid can help.
- Don’t be surprised by swelling above the level of the garment. It is not possible to provide compression over the upper abdomen, because this might restrict breathing. Don’t worry, this swelling will go down and you will not be left with a ledge over the top of the garment.
- Bruising usually occurs in the flanks and back due to the effects of gravity.
- Usually the discomfort is in the flanks and back and caused by liposuction, which is usually performed simultaneously with the abdominoplasty.
- Wash the garment and then dry in a no-heat dryer. Keep the bottom of the garment, at the knees, partially zipped up so the garment does not get completely tangled up in the wash.
- Avoid any activities that stress the abdominal muscles.
- Avoid taking too many painkillers. A side effect is nausea. It is very uncomfortable to vomit after a tummy tuck. So don’t take more than two tablets every 4 hours. You can take one and a half painkillers or substitute a Tylenol for the second painkiller. It is important to treat pain, but avoid overtreatment which can produce nausea.
- Most of the sutures dissolve. The belly button sutures are typically removed about two weeks after surgery. The Steri-Strips along the abdominoplasty incision are left on for about a week, but don’t worry if some of them come off sooner. You can take the Band-Aids off the liposuction incisions when you first bathe after surgery (or sooner if any are saturated). Usually, you don’t need to replace these, but if there is any drainage go ahead and put on another Band-Aid.
- There will be swelling above the garment, where there is no compression, and along the lower abdomen. This swelling along the incision line can feel very firm. Gradually it softens. It takes a few months for this swelling to go down and for the tissues to feel soft again.
- The pubic area will be swollen and may be bruised. This is from liposuction (if this area is treated) or just from fluid and blood settling after the abdominoplasty. Even the labia (or scrotal area in men) can be swollen and bruised. Don’t be alarmed by this.
Q: How much weight can you take off?
A: Actually, the weight of the tissue removed at surgery is not as much as you might think, typically less than 10 pounds or so. However, large sections of skin are typically removed and this can make a dramatic difference in appearance.
Q: How much surgery can be done at one time?
A: Patients usually want to have as much done at one time as possible to maximize their result and reduce trips to the operating room. However, it is rarely possible to achieve all the goals in one operation. Usually the priorities are treated first. The surgeon makes a judgment about what combination of procedures can be done in a reasonable time frame, while not incurring excessive blood loss. My own practice is to limit surgery times to about 6 hours. However, with efficient use of operating time and techniques to reduce blood loss, quite a bit can be done in this time.