By Pat Speer
Morbidly obese patients are finding bariatric surgery the preferred treatment option – at astounding rates. Fueled in popularity by the likes of celebrities Carnie Wilson and NBC weatherman Al Roker, more than 100,000 patients will have bariatric surgeries in 2003, up from 63,000 in 2002, according to the American Society of Bariatric Surgeons, Gainesville, Fla.
“There is an increased recognition of the significant morbidity that accompanies obesity,” notes PSEF past President David Larson, MD, of Milwaukee’s Medical College of Wisconsin. “Plus, there is an increased awareness of the mechanisms of obesity and new appreciation of its pathology.”
Simply put, bariatric surgery has become safer, suggests Joseph Capella, MD, Ramsey, N.J. “This is largely due to improved stapling devices, surgical methodology, and greater expertise and experience on the part of the surgeon dedicated to this procedure.”
Patients who undergo bariatric surgery often experience a variety of medical improvements. Yet most of these patients still face a rude awakening: As the massive volume of fat drips away, much of the skin stays.
“There is a tremendous number of people who come to me and say ‘no one told us what we would look like after losing all this weight,’” says Al Aly, MD, Iowa City, Iowa. “Many of them are quite distraught and it can be quite a psychological downturn for them.” So much so that patients are beating a path to the plastic surgeon’s door seeking weight loss-related plastic surgery.
Dr. Aly used to see one or two patients per month. “Now I see four to six per week,” he says, “and my partner sees two to three per week – that’s five to 10 new patients per week. This is absolutely the new frontier of plastic surgery.”
Dr. Aly, who studied with the late Fred Grazer, MD, one of the first U.S. surgeons to tackle this problem, specializes in the surgery with colleague Al Cram, MD, at University of Iowa Hospital. Patients come from Florida to California and from overseas. “Five years ago, the average plastic surgeon may have seen a handful of these cases in their lifetime,” notes Dr. Aly.
Close to 75 percent of Dr. Capella’s plastic surgery practice is dedicated to weight loss patients. Double-boarded in plastic and general surgery, Dr. Capella shares a practice with his father, a board-certified general surgeon. This year, Dr. Capella and his father will perform 400 Roux-en-Y gastric bypasses. Just four years ago, the team tallied 120 such procedures.
“The demand for bariatric surgery and weight loss plastic surgery has exploded,” says Dr. Capella, who specializes in body lifts (circumferential panniculectomy or belt lipectomy) and performs one to three procedures per week – a pace of about 100 per year. “Plastic surgeons have yet as a whole to appreciate the magnitude of growth in this area.”
Ted Lockwood, MD, Overland Park, Kan., agrees. Known for developing the more extensive “body lift,” technique, Dr. Lockwood maintains that the problem is that “we are not ready as a specialty to deal with the increase in numbers.”
For those plastic surgeons who are prepared to deal with the onslaught of new weight-loss patients, choosing the appropriate procedure for the patient is also a question.
“The vast majority of patients are not treated properly after a major weight loss,” says Dr. Capella. “Many surgeons are hesitant to perform body lifts because they have minimal, if any, experience with this technique.”
Dr. Aly points to another complicating factor: general or bariatric surgeons who tell patients that they don’t need a plastic surgeon and offer their own services instead. “It may be our next turf war, because these surgeons don’t understand the concepts behind the repair work needed,” Dr. Aly says.
And for some plastic surgeons accepting these cases, says Dr. Aly, the tendency is to offer anterior abdominal contouring only. “For most of the patients who have had massive weight loss, abdominoplasty is not the appropriate procedure,” he says. “With relatively normal patients who do not have a significant amount of circumferential excess skin to remove, lateral dog ears are not a problem. But with weight loss patients, lateral bulges can be accentuated, and the back and buttocks are not addressed. In a sense, you end up hurting them by not properly addressing all of their problems.”
Dr. Larson performs four cosmetic procedures for each obese panniculectomy. “They have so much extra skin that, at times, you don’t know where to start,” he says. “They are human Shar-Pei dogs, with folds and folds of skin. They want to feel better and look better in their clothes and thankfully don’t care as much about the scarring, which will be extensive.”
A panniculectomy eradicates the massive pannus, while the circumferential belt lipectomy focuses on the trunk. Body lifts use the same circumferential incision but lift the thighs and buttocks at the same time. All procedures require extensive experience and great surgical skill.
The key to determining the appropriate procedure, notes Dr. Lockwood, is in treating each patient as unique. “Each patient presents differently, yet we have a tendency to treat all cases with the same, using time-worn procedures,” he says.
Dr. Lockwood points to the panniculectomy, which was developed more than 100 years ago, and the circumferential belt lipectomy, performed since about 1940.
“These procedures are OK as a first step, but these patients’ problems are severe,” he says. “After massive weight loss there is often familial fat left over that resides in skin that is saggy, floppy. We know now where the tissue falls from, so we know where to make the incision to avoid major blood loss. With these improvements in technique, we can’t just deal with the trunk. The buttocks and thighs must also be addressed. The area we are trying to sculpt is huge and uniquely complex, so in terms of a sculpture, these areas must be in balance.”
Regardless of the procedure, extensive weight-loss related surgery is a serious undertaking not offered in many places around the country, explains Dr. Aly. “If it is offered, it’s difficult to find surgeons with significant experience. What we consider significant experience is having performed at least 20 of these surgeries. It’s an operation that requires all the skill of the surgeon and full cooperation of the patient, because the patient will need to withstand an arduous process.”
Unlike an abdominoplasty, which is usually performed under general anesthesia in an outpatient surgery center with an overnight stay or as inpatient surgery if the patient has particular risk factors, these extensive surgeries require from four to eight hours on the operating table and several days of in-patient, challenging recovery.
“I tell my patients ‘you’ve come this far, now you must challenge your physiological and psychological makeup to come through the procedure,’” Dr. Aly says. “The surgeon must be able to hold the patients’ hand through this and get them through the tough times during recovery.”
Such surgeries carry with them great risk, and complications are common, including delayed healing, infection and breakdown of wounds.
“The muscles and skin are very tight,” says Dr. Capella, “and the incision (for a circumferential panniculectomy) is much more extensive than a simple abdominoplasty. I explain to patients that a body lift will take approximately four hours under general anesthesia. The patient can expect a two- to three-night stay in the hospital. The patient will have six drains, which are removed in stages postop. They are told that they must plan to take at least three weeks off from work, and should not resume a full exercise regime for at least seven to eight weeks.”
Other complications specific to belt lipectomy include seroma formation around the back area, which is usually treated by repeated needle aspirations. Wound separation is another possible risk and requires careful postop management. Patients who undergo extensive procedures also face the risk of pulmonary embolus.
Patients who have undergone bariatric surgery and overcome a lifetime of obesity-related illness, such as severe arthritis, diabetes, hypertension, high blood cholesterol and coronary heart disease, are willing to face those risks, however.
“These patients are motivated,” says Dr. Capella. “Their results are dramatic, often times 15 lbs. or more of skin is removed. As a plastic surgeon, you quickly become a fan of this procedure when you see your patient’s immediate life-changing results. A colleague of mine remarked that he had become a “body lift junkie” after performing his first several body lifts.”
Dr. Aly describes a patient’s follow-up exam. She asked for a full-length mirror and upon seeing herself, cried. This was the first time she had been able to look down and see beyond her abdomen.
“When you do this kind of surgery, you are very lucky to be able to change peoples’ lives in this way,” Dr. Aly says. “Many people have worked hard to get to this point with their weight. But without this contouring surgery, they still feel and look like they are fat people. Within a week’s period, you have transformed their lives. It’s incredibly gratifying.”
With improved self-esteem, quality of life, mobility and stamina, interpersonal effectiveness and lessened self-consciousness, most patients come back for additional cosmetic surgery.
“This represents a tremendous opportunity for the plastic surgery specialty,” predicts Dr. Capella, “and will really help promote reconstructive surgery as a gateway to other cosmetic procedures.”
Dr. Aly sees a bridge to that gateway: educating the public and the plastic surgeon on these new techniques. “It’s important to educate the public that choosing a board-certified plastic surgeon is the only way to go for this,” he says.
Dr. Lockwood predicts that within five years, endoscopic bariatric surgery will be the predominant strategy, making bariatric surgery even safer and hospital stays shorter. “In the coming years, we will be flooded with these cases,” says Dr. Lockwood.
Because patients having both bariatric and post-weight loss surgery will require in-patient hospital care, Dr. Lockwood suggests plastic surgeons find a hospital that will provide cost-effective treatment.
“Our biggest challenge will be to make the procedure as affordable as possible to the patient, because often times the patient is required to pay a good portion out of pocket. Since hospitals often consider these procedures ‘low profit,’ it’s important to also perform some of your cosmetic cases at the hospital; that way, the hospital gets more business and will be less likely to pass along higher costs.”
Dr. Lockwood is confident that the long-term outlook on weight loss-related surgery is a positive one: “Even with the explosion of these [bariatric and weight loss] surgeries, there are still a higher proportion of people getting fat.”
-Plastic Surgery News
July 2003
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