Jeffrey A. Gusenoff

Body mass and surgical complications in the postbariatric reconstructive patient: analysis of 511 cases.

Objective:To analyze the impact of body mass indices on postbariatric reconstructive surgery complications. Background:An increasing number of patients are presenting after massive weight loss due to bariatric surgery or diet and exercise. Many of these patients have residual obesity, which may compromise outcomes. Methods:449 patients were enrolled in a prospective registry over 6 years. Measures included medical complications and comorbidities. All cases were analyzed together as well as in two subgroups: single procedure cases (Group I) and multiple procedure cases (Group II). Results:449 patients (407 female, 42 male) with a mean age of 44.5 ± 10.3 underwent 511 separate operations. Mean pre-weight loss BMI (Max BMI) was 51.6 ± 9.5 kg/m2, post-weigh loss BMI (Current BMI) was 29.3 ± 5.0 and the ΔBMI was 22.3 ± 7.5. For all cases (n = 511), the presence of a surgical complication was directly related to Max BMI (P = 0.002) and ΔBMI (P = 0.002) but not Current BMI. Group I consisted of 194 single procedure cases. Complications in Group I were related to Max BMI (P = 0.006) and Current BMI (P = 0.02) but not ΔBMI. Max BMI impacted infections (P = 0.003) while Current BMI impacted dehiscence (P = 0.009) and infections (P = 0.03). Group II consisted of 317 cases with only ΔBMI directly related to overall complications (P = 0.01). Conclusions:Body mass indices influence complications in postbariatric reconstructive surgery. Current BMI may impact complications in single-procedure cases, but appears to play less of a role in larger cases. Careful patient selection, assessment of surgical complexity, and recognition of the particular risks increased by residual obesity can help to optimize outcomes in this patient population.

Temporal and Demographic Factors Influencing the Desire for Plastic Surgery after Gastric Bypass Surgery

Background: An increasing number of gastric bypass patients desire plastic surgery after massive weight loss. However, the timing of interest and factors influencing the desire for body contouring have not been studied. Methods: Two thousand five hundred one gastric bypass patients were surveyed. Outcome measures included years since gastric bypass, laparoscopic versus open procedures, body mass indexes, income, prior plastic surgery, desire for body contouring, and need for a payment plan. Multiple variables were assessed by univariate and multivariate analysis. Results: Nine hundred twenty-six patients (817 women and 109 men; mean age, 47.2 years) responded. Eight hundred eleven patients were considering body contouring: 685 patients (84.5 percent) desired body contouring after gastric bypass and 126 wanted no further surgery (15.5 percent). Desire was inversely related to age (p < 0.0001), years since gastric bypass (p = 0.052), and open versus laparoscopic gastric bypass (p = 0.04), but was two times more likely in women (p = 0.008) and divorced versus married individuals (p = 0.04). Patients desiring a payment plan were younger (p = 0.0210) and had lower post–gastric bypass body mass indexes (p = 0.007). Age was inversely related to desire for a payment plan but directly related to the inability to afford or lack of desire for body contouring (p = 0.02). Conclusions: A majority of post–bariatric surgery patients desire body contouring; younger, divorced, female patients who had laparoscopic gastric bypass voiced the strongest interest in body contouring. Thus, efforts should be directed toward facilitating body contouring in this subpopulation because they appear the most motivated.

Brachioplasty and concomitant procedures after massive weight loss: a statistical analysis from a prospective registry.

Background: A growing number of massive weight loss patients are undergoing brachioplasty. The authors analyzed data from a prospective registry of massive weight loss patients who underwent brachioplasty alone or with concomitant operations to identify statistically significant complications. Methods: One hundred one massive weight loss patients underwent brachioplasty. Outcome measures included operative time; time since gastric bypass; need for revision; arm liposuction; and complications such as seroma, dehiscence, hematoma, infection, and nerve injury. Univariate analyses were performed to assess outcome measures. Results: One hundred one patients (97 women and four men; mean age, 45.9 ± 10.1 years; mean body mass index, 29 ± 3.9) with a mean time since gastric bypass of 28.5 months (range, 7 to 252 months) underwent brachioplasty. Ninety-seven patients (96 percent) had concomitant body contouring procedures; 23.8 percent had concomitant arm liposuction; and 36 patients had complications related to their arms, mostly in the form of a seroma, whereas dehiscence, infection, and hematoma were more prevalent with the concomitant procedures. Patients with a greater change in body mass index had a higher chance of wound infection (odds ratio, 1.1; p = 0.028). Longer operative time was associated with increased rates of surgical complications (p = 0.003; odds ratio, 3.8) at the operative site. There was a trend toward increased complications when arm liposuction was combined with brachioplasty (odds ratio, 2.5; p = 0.05). Conclusions: Brachioplasty is a safe and effective method of treating upper arm deformity in the massive weight loss patient. Although patients with greater weight loss are likely to present for longer contouring procedures and are at highest risk for wound-healing complications, these complications occur most frequently in areas other than the arms.

Plastic Surgery After Weight Loss: Current Concepts in Massive Weight Loss Surgery

The authors begin their discussion of current concepts in massive weight loss (MWL) surgery by offering terminological guidelines that help define reconstructive and aesthetic concepts and procedures for the post-MWL patient. Measures for effective preoperative nutritional and metabolic screening include assessment of weight fluctuations over time, constitutional symptoms, and medications and nutritional supplements. Although there is no established body-mass index (BMI) threshold above which surgery should be refused, higher BMIs have been associated with increased complications. Residual medical problems and psychosocial issues require assessment before surgery, with appropriate specialist consultation as necessary. Consultation with patients concerning the different expectations for functional versus aesthetic procedures and issues such as postoperative scarring and the common incidence of wound healing problems is essential. Patient safety is paramount in decisions to combine multiple procedures and plan stages. The authors often recommend combining abdominoplasty and mastopexy. Surgeon experience, operative setting, and a patients medical status are factors which influence how much surgery should be performed in the same operative setting. Centers of Excellence in body contouring that provide a team approach combining comprehensive patient evaluation, outcomes research, and surgical training may be the optimal approach for treating the massive weight loss patient.

Patterns of plastic surgical use after gastric bypass: who can afford it and who will return for more.

Background: More patients are undergoing plastic surgery after gastric bypass. Socioeconomic factors influencing the decision to have body contouring after gastric bypass have not been studied in the current literature. Methods: In this study, 2501 consecutive gastric bypass patients were surveyed. Outcome variables were assessed by univariate and multivariable analyses. Results: Nine hundred twenty-six patients (817 women and 109 men) responded (40.3 percent of the 2296 surveys that at least may have been received), with a mean follow-up of 2.4 years. One hundred five (11.3 percent) underwent body contouring. Thirty-four patients assumed all costs for body contouring, and of these, 47 percent had multiple operations. Sixty-eight patients had some insurance coverage; 26 percent of these patients personally paid for additional body contouring. Having multiple procedures was not explained by any variables in our model. Body contouring was related to years since gastric bypass (p < 0.0001), post-gastric bypass body mass index (p < 0.03), change in body mass index (p < 0.0001), open versus laparoscopic gastric bypass (p < 0.0001), and income category greater than

A Comparative Analysis and Systematic Review of the Wound-Healing Milieu: Implications for Body Contouring after Massive Weight Loss

20,000 (p < 0.03). Expenditures for body contouring were greater if the patient assumed costs versus had some insurance (p < 0.03), but were not related to income. Patients who assumed all costs of body contouring had lower pre-gastric bypass and post-gastric bypass body mass indexes (p < 0.007). Conclusions: A minority of patients underwent body contouring. Patients assuming the costs of body contouring were twice as likely to have additional surgery. These results suggest that socioeconomic factors play an important role in the decision to have body contouring but may not predict who will have concomitant or additional procedures.

Medial thigh lift in the massive weight loss population: Outcomes and complications

Background: Wound-healing complications following body contouring for massive weight loss patients are significant, with rates exceeding 40 percent. To better understand aberrant healing in this population, the authors have performed a comparative analysis of the wound milieu literature for patient populations with similar complication rates. Methods: PubMed and Ovid databases were reviewed from January of 1985 to January of 2009 for key terms, including wound healing, obesity, cancer, burn, transplant, and body contouring. Serum and wound levels of multiple factors, including matrix metalloproteinases (MMPs) and cytokines, were assessed. Results: Complication rates in body contouring surgery range from 31 to 66 percent. Sixty-five studies were reviewed, and wound-healing complication rates were identified for cancer (45.8 percent), burn (30.4 percent), posttransplant (36 percent), and obese (43 percent) populations. In these groups, matrix metalloproteinases and tissue inhibitors of metalloproteinase (TIMPs) help regulate wound repair. Matrix metalloproteinase levels were elevated in cancer (4-fold increase in MMP-2), burn (20- to 30-fold increase in MMP-9), transplant (1.4-fold increase in MMP-2), and obese/chronic (79-fold increase) populations. TIMPs were increased in cancer (1.9-fold increase in TIMP-2) and burn (1.4-fold increase in TIMP-1) patients but decreased in chronic wound (55-fold decrease in TIMP-1) populations. Alterations to these regulatory proteins lead to prolonged matrix degradation, up-regulation of inflammatory mediators, and decreased growth factors, delaying the wound-healing process. Conclusions: Complications after body contouring surgery are likely multifactorial; however, molecular imbalances to the massive weight loss wound milieu may contribute to poor surgical outcomes. Examining wound regulatory proteins including transforming growth factor-β, vascular endothelial growth factor, and matrix metalloproteinases could aid in understanding the healing difficulties observed clinically.

Multiple Procedures and Staging in the Massive Weight Loss Population

Background: Complication profiles of medial thighplasty in the massive weight loss population are not well described. The authors present their experience with these procedures in the massive weight loss population. Methods: Thighplasty patients from 2003 to 2012 were assessed. Variables included age, sex, body mass index, method of weight loss, comorbidities, and smoking status. Outcomes included seroma, dehiscence, infection, hematoma, edema, and revision. Statistical analysis was performed as appropriate. Results: One hundred six subjects (90 women and 16 men) underwent thighplasty. Fourteen patients underwent horizontal thighplasty, with a complication rate of 43 percent; 24 underwent short-scar thighplasty, with a complication rate of 67 percent; and 68 underwent full-length vertical thighplasty, with a complication rate of 74 percent. Seventy-two subjects (68 percent) had at least one complication. Complications included dehiscence (51 percent), seroma (25 percent), infection (16 percent), and hematoma (6 percent). Overall, 25 patients (23 percent) developed edema, which did not resolve in two patients by 12 months. Hypertension was significantly associated with postoperative seroma (p = 0.02). Age (p = 0.01), hypothyroidism (p = 0.01), and liposuction outside the area of resection (p = 0.025) were associated with postoperative infections. A full-length vertical incision was associated with increased lower extremity edema (p = 0.007). Conclusions: Medial thighplasty has a high rate of minor wound healing problems. Full-length vertical thighplasty is associated with prolonged edema. Concomitant liposuction may also increase complications. Patients should be counseled appropriately about the potential for minor wound healing problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A multicenter randomized controlled trial comparing absorbable barbed sutures versus conventional absorbable sutures for dermal closure in open surgical procedures.

Background: Unlike traditional plastic surgery patients who present with a specific anatomical complaint, massive weight loss patients often have multiple regions of concern. No single procedure can address the whole-body deformities associated with massive weight loss. The authors sought to quantify their clinical experience to provide evidence-based analysis of procedural combination in body contouring. Methods: Patients were enrolled in an institutional review board–approved prospective clinical database over a 5-year period. Procedure categories included breast, medial thigh lift, buttock and lateral thigh lift, upper back lift, brachioplasty, and abdomen. Analysis of variance was used to analyze differences between procedure combinations. Results: Six hundred nine massive weight loss patients underwent 661 cases involving 1070 procedures. Length of hospital stay increased with the number of procedures performed (p < 0.001). Second-stage cases (n = 60) had similar complication rates and length of hospital stay. Seroma and dehiscence were strongly correlated with the number of procedures (p < 0.001), as were tissue necrosis and infection (p = 0.02), whereas hematoma was unrelated (p = 0.25). Major complications did not increase in multiple-procedure cases. Conclusions: In a large experience at a high-volume center, concomitant procedures were performed safely in carefully selected patients with low major complication rates. Although aggregate minor complication rates were predictably higher than in single-procedure cases, there was no significant increase on a per-procedure basis. Multiple procedures can be combined safely in the body contouring patient, with surgical staging offering a viable alternative for patients who are unable to undergo combined procedures.

Dermal Suspension and Parenchymal Reshaping Mastopexy after Massive Weight Loss : Statistical Analysis with Concomitant Procedures from a Prospective Registry

BACKGROUND Barbed sutures were developed to reduce operative time and improve security of wound closure. OBJECTIVE The authors compare absorbable barbed sutures (V-Loc, Covidien, Mansfield, Massachusetts) with conventional (smooth) absorbable sutures for soft tissue approximation. METHOD A prospective multicenter randomized study comparing barbed sutures with smooth sutures was undertaken between August 13, 2009, and January 31, 2010, in 241 patients undergoing abdominoplasty, mastopexy, and reduction mammaplasty. Each patient received barbed sutures on 1 side of the body, with deep dermal sutures eliminated or reduced. Smooth sutures with deep dermal and subcuticular closure were used on the other side as a control. The primary endpoint was dermal closure time. Safety was assessed through adverse event reporting through a 12-week follow-up. RESULTS A total of 229 patients were ultimately treated (115 with slow-absorbing polymer and 114 with rapid-absorbing polymer). Mean dermal closure time was significantly quicker with the barbed suture compared with the smooth suture (12.0 vs 19.2 minutes; P<.001), primarily due to the need for fewer deep dermal sutures. The rapid-absorbing barbed suture showed a complication profile equivalent to the smooth suture, while the slow-absorbing barbed suture had a higher incidence of minor suture extrusion. CONCLUSIONS Barbed sutures enabled faster dermal closure quicker than smooth sutures, with a comparable complication profile. LEVEL OF EVIDENCE 1.