Body Contouring, An Issue of Clinics in Plastic Surgery (eBook)

J. Peter Rubin-DUPLICATE DO NOT USE (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-32629-2 (ISBN)

Infos

This issue of Clinics in Plastic Surgery offers the surgeon information on the most recent approaches to body contouring, primarily focused on this procedure performed after massive weight loss. Gastric bypass surgery practically foretells abdominoplasty, with -75% of patients undergoing plastic surgery following gastric bypass. A total of almost one-half million body contouring procedures are performed annually by plastic surgeons according to ASPS statistics. Topics in this issue include: Assessing outcomes in body contouring; Preoperative evaluation of the body contouring patient; What happens to the skin after weight loss; Effect of further weight loss following body contouring; Effect of weight gain following body contouring; Anesthesia considerations; Procedures for Brachioplasty; Bra line back lift; Breast contouring; Abdomen contouring; the Fleur Di Lis Abdominoplasty; Extended abdominoplasty; Medial thigh lift; Buttock contouring; Truncal contouring; Lower body lift; and Prevention and management of complications.

Textauszug

Preoperative Evaluation of the Body Contouring Patient

The Cornerstone of Patient Safety

Nima Naghshineh, MD, MSc and J. Peter Rubin, MD∗[e-mail],     Department of Plastic Surgery, University of Pittsburgh Medical Center, 6B Scaife Hall, Suite 690, 3550 Terrace Street, Pittsburgh, PA 15261, USA

∗Corresponding author.

The obesity pandemic has resulted in increasing cases of bariatric surgery and subsequent issues related to excess skin and laxity for patients. This patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the issues of the body contouring candidate and provides tools that may assist in surgical planning.

Keywords

Body contouring

Bariatric surgery

Skin laxity

Weight loss

Skin excess

Nutritional evaluation

Key points

• Body contouring after massive weight loss is often the final phase of a long and positive journey for the bariatric patient.

• As the prevalence of obesity increases and many more continue to seek bariatric and subsequently body contouring surgery, it is critical that plastic surgeons become well versed in not only techniques that address skin laxity, but also more familiar with the unique set of issues that the postbariatric patient presents.

• A careful and comprehensive approach like the one presented in this article allows for safe and effective treatment of these patients.

Introduction

As a result of the obesity pandemic, more and more individuals are seeking bariatric surgery for weight loss and resolution of conditions related to obesity. As the numbers have risen to greater than 200,000 cases per year, the number of postbariatric massive weight loss patients presenting to the plastic surgeon for body contouring to address excess skin laxity is increasing.1 However, this patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the body contouring candidate and provides tools that may assist in surgical planning.

We have identified six key assessment points as part of a comprehensive evaluation of the massive weight loss patient presenting for potential body contouring surgery: (1) time from gastric bypass to body contouring procedures; (2) body mass index (BMI) at presentation; (3) evaluation of medical comorbidities; (4) nutritional assessment; (5) psychosocial status; and (6) physical deformities and potential for combined procedures. An overview of these points is presented in Box 1.

Box 1   Summary of key points in evaluation of the weight loss patient

BMI

Best candidates have reached a BMI <30

Functional operations preferred for higher BMIs with associated physical impairments

Timing

Minimum 12 mo after bariatric surgery

Weight stability for a minimum of 3 mo

Medical comorbidities

Many resolve following bariatric surgery, but residual disease states must be investigated

Tight glycemic control for diabetics

Cardiac evaluation for patients with concerning symptoms or sedentary lifestyle

Rigorous work-up for history of deep venous thrombosis or pulmonary embolism and prophylaxis

Appropriate use of medical consultants

Nutritional status

Identify type of bariatric procedure performed

Assess protein intake by history, with a goal of 70–100 g/day before body contouring surgery

Document supplements used

Assess for signs of micronutrient deficiency

Supplement micronutrients (eg, iron, vitamin B12, calcium) as needed

Refer patient back to bariatric surgeon if there is protracted nausea/vomiting or weight loss plateau at unacceptably high BMI

Psychological status

Establish rapport early in initial consultation

Ask patients to describe their concerns and clearly delineate goals and priorities in their own words

Emphasize the tradeoff of skin for scar

Assess for reasonable patient expectations

Depression is pervasive

Evaluate for physical and emotional support networks

Patients with known or suspected body dysmorphic disorder, bipolar disorder, or schizophrenia should undergo a mental health evaluation

From Bossert RP, Rubin JP. Evaluation of the weight loss patient presenting for plastic surgery consultation. Plast Reconstr Surg 2012;130(6):1363; with permission.

Preoperative evaluation and procedure timing

Initial preoperative history should focus on age of onset of obesity, family history of obesity, type and date of bariatric surgery performed, and course of weight loss since surgery. Anthropometric measures should include height, weight (highest, lowest, and current), and BMI. Determination regarding patient’s weight stability should be made because many patients have a 12- to 18-month period of continued weight loss after their bariatric surgery. Inquiry into weight changes over the past 1 and 3 months before presentation should be made as part of the patient’s history. We define weight stability as no more than an average of 5 lb/month loss over 3 months. A patient still undergoing significant weight loss may be in a state of protein-calorie deficiency and consequently may be at risk of suboptimal wound healing. Those deemed not stable are delayed and reevaluated in 3 months. An overview of our timing of surgical planning is provided in Box 2.

Box 2   Timing of surgical planning

2-3 months before surgery

Initial evaluation

Weight loss history, evaluation of BMI (maximum, current, and change)

Medical and surgical history

Evaluation of medical comorbidities

Social history evaluation

Nutritional analysis

Psychological evaluation

Physical examination

Delineation of patient goals and management of expectations

Photographs are taken

Follow-up visit 2-3 mo if further weight loss/weight stability is needed

1 month before surgery

Formal preoperative visit

Surgical plan reviewed

Questions answered

Informed consent obtained

Preoperative laboratory blood specimens are drawn

Preoperative medical evaluations should be performed as necessary

2 weeks before surgery

Antiplatelet medicines (e.g. aspirin, NSAIDs) are discontinued

Laboratory tests and medical clearances are reviewed

Nutrition is optimized

Day before surgery

Light bowel preparation (1/2 bottle of magnesium citrate at noon, followed by clear liquids) is administered for all abdominal procedures

Transportation in confirmed

Surgical plan and photographs are reviewed by the surgical team

From Bossert RP, Rubin JP. Evaluation of the weight loss patient presenting for plastic surgery consultation. Plast Reconstr Surg 2012;130(6):1363; with permission.

Patient BMI

Provided the patient has achieved weight stability, evaluation of BMI can be an indicator of potential complications and aesthetic outcomes. We consider patients with BMI less than 30 kg/m2 to be the best candidates for a wide range of procedures and combinations thereof.2 A prospective study of 511 postbariatric body contouring cases revealed that higher prebariatric maximum BMI and BMI at time of presentation were associated with increased complications in patients undergoing single procedures.3 Similarly, the degree of change between these two measures (maximum BMI and BMI at time of presentation) was found to be...

Produkt-Details

• Erscheint lt. Verlag: 17.10.2014
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Chirurgie ► Ästhetische und Plastische Chirurgie
• ISBN-10: 0-323-32629-3 / 0323326293
• ISBN-13: 978-0-323-32629-2 / 9780323326292