Are We Doing Enough for Our Patients?

By Anna Goldenberg Sandau, DO

imageWith obesity on the rise, the number of Americans undergoing bariatric surgery has increased exponentially over the past several years. Estimates show that in the United States, doctors perform more than 220,000 bariatric surgeries annually. Although most of the research to date focuses on the physiologic effects of this procedure, very little information is available on the psychological significance of bariatric surgery to the patient. Specifically, most bariatric surgeons do not factor in the influence of body contouring when measuring the success of bariatric procedures. Therefore, the question remains, should all preoperative bariatric consultations include a trip to the plastic surgeon, and if so, is the medical community behind in our understanding of the psychological and functional significance of body contouring after bariatric surgery?

Figure 1a. Excess arm skin and loss of skin elasticity after weight loss surgery.
Figure 1b. Two months postoperative from brachioplasty with removal of excess skin and fat deposits. Incision is well hidden in the inner arm into the axilla.

Losing a massive amount of weight is a life-changing event for a patient, and the effects often unfold over time. Both plastic and bariatric surgeons recommend that a patient should have a stable weight for six to 12 months before undergoing any contouring procedures. During the process of “soft tissue deflation,” most patients experience secondary emotional and physical disability. According to a study on body image and a patient’s quality of life after massive weight loss, “as increasing numbers of bariatric surgical patients achieve success, they are left with post-weight loss deformaties of loose, ptotic skin envelopes and residual adiposities that compose contour irregularities” (Obesity 2006;14:1626-1636).

These side effects can lead a patient to experience difficulties with hygiene, mobility and sexual health, as well as psychological difficulties. However, plastic surgery can alleviate many of the issues that arise for a patient after bariatric surgery. According to a study by Araco et al, “most of the altered body contours involving the abdomen, thighs and buttocks can be effectively corrected with lipectomy and body-lift procedures. Facial and neck skin redundancy can be corrected with rhytidectomy techniques, and mastopexy operations with or without augmentation have been used to lift and fill redundancy of the breast” (Aesthet Plast Surg 2006;30:374-376).

Benjamin Lam, DO, director of plastic and reconstructive surgery at Philadelphia College of Osteopathic Medicine, and an expert in body contouring in bariatric patients, believes that “plastic surgery in all its aspects is about harmony. Body image has both a mental as well as physical component. This is especially true in the bariatric population. After massive weight loss, this delicate balance is disrupted. Patients simply want to look as good as they feel. Having post-bariatric contouring is a way to achieve this balance.” He also believes that patient expectations must be discussed at length before any body contouring is performed. “Because skin elasticity is often compromised from the weight loss, patients have to be realistic about the final results,” Dr. Lam said.

Figure 2a. Skin deformity of upper thighs causing significant mobility and hygiene problems.
Figure 2b. After a thigh lift. This has proven to be an effective procedure for tightening loose, sagging skin in the buttocks, posterior thighs, hips, and outer and anterior thighs. Incisions pass from the back around the hips to the inner thighs. Incisions are well hidden in normally occurring anatomic folds.

In 2009, Warner J. et al, at the University of Wisconsin Division of Plastic and Reconstructive Surgery stated, “The surgical treatment of the obese population is multidisciplinary and should include both bariatric and plastic surgeons.”

In a national survey, (Plast Reconstr Surg 2009;124:926-933), researchers sent out 500 questionnaires to bariatric surgeons. Of the surgeons surveyed, 64% reported that patients asked about body-contouring procedures even before they underwent bariatric surgery. Ninety-six percent of bariatric surgeons had access to plastic surgeons, but only 7% reported referring their patients to a plastic surgeon postsurgery. fifty-one percent of surgeons reported that those patients who had undergone body-contouring procedures were more satisfied with their decision to undergo bariatric surgery than those who did not have these procedures. Additionally, 85% of bariatric surgeons believed that insurance policies should cover body-contouring procedures after massive weight loss.

These ideas are further supported by the fact that many bariatric surgery patients are seeking out body-contouring options on their own. Plastic surgeons have reported an increase in the number of patients requesting body contouring. “To many bariatric patients, plastic surgery is the icing on the cake, the end of a long journey. Yet some patients wear the extra skin as badges of honor,” said Marc Neff, MD, FACS, medical director of the Kennedy University Hospital Bariatric Surgery Program in Stratford, N.J. Dr. Neff believes that if patients know they will have to pay out of pocket for extra procedures, they might be deterred from asking about the procedures or seeking insurance coverage options.

Figure 3a (left). Overhanging skin after weight loss surgery often leads to unwanted rashes and morbid infections in skin folds.
3b. Post abdominoplasty with plication of the rectus muscles. Removal of excess skin and fat achieves a smooth contour to the abdominal wall and plication tightens the weakened rectus muscles.

Open dialogue between doctor and patient, and within the health care system as a whole, is changing the way the medical community views the effects of bariatric surgery. Many patients report shying away from asking their doctors for a referral to a plastic surgeon for information about body contouring because they are afraid of the potential financial burden. Currently, most insurance policies cover only a very small range of plastic surgery procedures, usually for debilitating rashes or mobility dysfunction. This sobering fact sways many bariatric surgeons away from referring patients to a plastic surgeon. Most studies on post-bariatric body contouring cite “the most frequent reason for not undergoing body contouring is the expense, and second, the lack of awareness regarding the options.” From this evidence, it is clear that health care providers and insurance companies should recognize the psychological and physical disabilities of massive weight loss, which are both functional and aesthetic.

Doctors should routinely engage in discussion about self-image and expectations with every bariatric patient in the early preoperative evaluation phase. They can provide additional information in the form of picture pamphlets, videos or even a free consultation with a plastic surgeon. Although research has shown that it is important for the medical community to consider the aesthetic aspect of post–bariatric surgery, a lot of work needs to be done before this becomes the status quo. Further research is necessary to assess the post-bariatric weight loss self-image phenomenon and how body contouring can improve the long-term quality of life for these patients.

Dr. Goldenberg Sandau is a surgical resident (postgraduate year-3) at the University of Medicine & Dentistry of New Jersey, Stratford.
Benjamin Lam, DO, and Marc Neff, MD contributed to this article.