Improving outcomes for post-bariatric patients

Body contouring after weight loss is a new area of practice which is highly specialised and challenging. Driven by rising levels of obesity, it is a rapidly expanding market and one of the fastest growing specialties. In the US, alone, there were around 78,000 cases of body contouring, following weight loss surgery, last year. According to David Floyd, a consultant plastic surgeon at the Royal Free Hospital in London, the UK is also witnessing a similar trend of rising demand in body contouring procedures – driven by an increase in bariatric surgery of 30% in the last year. Speaking at an Ethicon symposium at the Royal Free Hospital in London, he commented: “Because bariatric surgery is so successful, we are frequently presented with patients in our clinics that have undergone massive weight loss, who have breast ptosis, abdominal ‘aprons’ (or pannus), brachial skin laxity, thigh redundancy and back and flank excess. Our challenge is to understand how to treat these patients and, more importantly, whether we are able to treat them within the confines of the NHS.” “There is usually a two-year delay between presentation for bariatric surgery and carrying out the massive weight loss body contouring surgery. However, we anticipate an ‘avalanche’ of such cases in the immediate future and we need to prepare ourselves for what will inevitably be a high work load.” However, obtaining funding from PCTs and resistance towards the need for body contouring – after massive weight loss – remains a significant challenge according to Peter Butler, consultant plastic surgeon and honorary senior lecturer at the Royal Free and UCL hospitals. He pointed out that the UK is currently lagging behind the US in terms of provision and presented the results of a survey which indicated the need for a more unified approach to funding and inclusion/exclusion criteria in the UK. The results showed that two units out of 41 said they were unable to offer body contouring due to lack of PCT funding; around half only offered abdominoplasty, while the other offered abdominoplasty plus other procedures. However, the type of procedure available varied – procedures such as mastopexy were not as commonly available as he would have expected, for example, and there was no unification in terms of provision. Moreover, the majority did not include psychology screening in the pathway and inclusion/exclusion criteria varied widely. “There is definitely a postcode lottery out there,” he concluded, adding that demand for body contouring surgery is estimated to reach between 2,700 and 11,280 in 2010. This will include 289 cases per unit, per annum; 6.8 cases per week and 18 hours per week of theatre time – for abdominoplasty alone. In light of rising obesity levels, he questioned: “Are we ready to meet this demand?” and “What will the economic downturn mean for this service?” In the face of predicted funding growth of 0% (or possibly -1%) by 2010, he warned delegates: “We have a mountain to climb ahead of us – it is really important that surgeons start gathering evidence, now, to fight a restricting budget.”

How soon is too soon?

Consultant bariatric and upper GI surgeon, for St Richard’s Hospital in Chichester and the London Clinic, Shaw Somers highlighted some important safety issues in relation to aesthetic surgery and considered the question: “What is the optimum timing for massive weight loss body contouring after bariatric surgery?” He explained that, during the first 18 months of weight loss, patients are catabolic – which means that large wounds will not heal. He illustrated this problem by highlighting a case where one of his patients had visited a cosmetic surgery clinic, having been treated for early breast cancer a year post-bariatric surgery. “She approached the clinic for breast reconstruction, but the surgeon suggested she could have body contouring at the same time to remove her apron and to improve the appearance of her thighs and arms. Unfortunately, she was still catabolic and every one of her wounds broke down – the clinic did not call me to ask my advice first. It is really important to schedule surgery properly and to nutritionally screen patients first. Plastic surgery needs to be performed in a properly staged manner,” he asserted. After 18 months, in patients who have undergone a gastric bypass or duodenal switch, weight loss begins to stabilise and – as long as the patient is stable for at least three months – aesthetic surgery is appropriate and can be considered, he maintained. He pointed out that the period for gastric band patients is longer – at two to three years. “It is important that patients are nutritionally stable – their diet should be reviewed and their essential micronutrient levels must be checked,” he advised. “It is also important to look for easing of restriction. You need to know that their bypass has matured – i.e. that they can eat what they like, with the exception of certain foods, and are stable in their dietary habits. “In addition, if patients present with a gastric band at elective surgery, you should ensure they have their band released. There have been a number of high profile law suits in the US where this has failed to occur and patients have aspirated on their own secretions, postoperatively, and the surgeon and anaesthetist has been successfully sued,” he warned. In fact, patient safety was a theme that permeated throughout the symposium and various examples of best practice and technique were illustrated. A multidisciplinary programme based in Pittsburgh, in the US, was offered as an example where selection and screening of patients have been optimised, to ensure body contouring is carried out safely and with the best possible outcomes. Associate professor of plastic surgery at the University of Pittsburgh, Dr Peter Rubin’s “Life After Weight Loss Clinical Program” has become recognised as a pioneering model for the care of the postbariatric patient. He warned an audience of plastic surgeons against being “too aggressive with big operations” on patients with a high BMI and went on to explain that he often had to remind patients that body contouring is plastic surgery after weight loss, not plastic surgery for weight loss. Patients will often cite the fact that issues such as a large abdominal “apron” are hindering their efforts to lose further weight though exercise. However, patients who have not lost sufficient weight after a bypass are counselled and referred to a nutritionist, and helped to lose more weight before cosmetic surgery. “As a general rule, if a patient shows up with a BMI of 30 or below they will be considered a good candidate for any aesthetic procedures that the clinic offers. Between 30 and 35 (BMI), we are more selective with the ‘big’ operations and we have to look at their body type and morphology and, above 35, we will only look at functional operations. In short, the lower the BMI the more I am able to offer the patient,” he commented. The clinic screens for medical problems, while the surgeons are also wary of performing surgery on inactive patients – as exercise tolerance is a key indicator in terms of surgical risk. “For patients in their fifties who have lost a lot of weight, but are very sedentary, we order stress tests,” he explained. Nutritional considerations are also extremely important, he added, and a key factor is the type of bariatric surgery previously undergone. “If the patient has had a restrictive operation there are less likely to be problems with nutritional deficiencies, but they still exist,” he continued. “If the patient has had a Roux-en-Y procedure – which is restrictive and malabsorptive – there is a greater likelihood of problems. A duodenal switch or biliary diversion operation in a patient’s history should be a red flag, however. They are hugely malabsorptive.” He advised that such patients should be referred to a bariatric surgeon for an evaluation before any body contouring is considered. It is also important to establish whether patients are experiencing any nausea, vomiting or dumping. “If they are experiencing vomiting and nausea more than a year after bypass, send them back to the bariatric surgeon – do not touch them,” he warned. “It is likely they have a mechanical stricture that needs to be dealt with and you can be sure that they are not getting adequate nutrition. Dumping may also indicate that they are nutritionally depleted.” The most significant factor in this patient population is protein intake as patients may develop food intolerances to protein sources and many will not be receiving adequate protein. Although patients need 75-100 g of protein per day, a nutritional evaluation of 237 patients after gastric bypass found that 15% were consuming less than 40g of protein per day. “This may be fine when the body is in an unstressed state, but when you stress patients with major surgery, they may not have enough protein to adequately heal their wounds,” he pointed out. Dr Peter Rubin further highlighted the results of a study which showed that just under half of patients experienced dumping after bariatric surgery and around 20% had dumping at presentation to the plastic surgeon. When they looked at serum protein measures, around 14% had a low albumin and 6.5% had a low pre-albumin level. However, the researchers discovered that patients with a good protein intake may also have low albumin or prealbumin levels. Patient reports on protein intake did not necessarily correlate with albumin and pre-albumin measurements, therefore. He pointed out that, although assessment of protein intake via nutritional examination is useful and protein intake should be boosted if necessary, this measurement is not sensitive enough to detect who will have a low serum protein. A low measure of serum protein is a known risk factor resulting in wound healing complications and should also be evaluated, he concluded.