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Body Contouring After Gastric Bypass Surgery

by Don Revis Jr., MD, FACS - April 2004

With the growing popularity of bariatric surgery as a treatment for obesity, body contouring after significant weight loss has become a field of special interest for many plastic surgeons.

By applying the latest techniques in body sculpting individualized to each patient’s specific needs and priorities, your plastic surgeon can help you realize the new shape that is hidden beneath the excess skin that remains after your goal weight has been achieved.

With significant weight loss over a relatively short period of time (usually 15-18 months), the remaining skin often does not retain the elastic qualities necessary to “shrink back down” to your new underlying shape. This often leaves patients with excessive amounts of hanging skin that creates a multitude of problems such as daily hygiene and finding clothes that fit properly.

A comprehensive approach to the bariatric patient is necessary to achieve the optimal figure following weight loss. One of the most important considerations for a plastic surgeon to realize is that a bariatric patient must be treated differently from non-bariatric body contouring patients. What has worked well for many years on other patients simply does not provide adequate shaping and contouring for the bariatric patient.

Patients who have undergone weight loss surgery and the subsequent significant weight loss may have numerous but similar areas of concern. These areas include:
• Breast ptosis, or droopiness, as well as a loss of breast volume. Mastopexy is a procedure to lift the breasts and may be performed with or without the addition of breast implants to improve shape, fullness and cleavage.
• Sagging of the facial skin. Facelifting, forehead lifting and eyelid surgery may be necessary to achieve complete facial rejuvenation, or you may be a candidate for endoscopic or minimally invasive techniques.
• Excess abdominal skin and a laxity of the muscles of the abdominal wall, sometimes with an accompanying hernia. Abdominoplasty or a
lower body lift procedure can contour the abdomen, hips and buttocks.
• Hanging skin under the arms. Brachioplasty is a technique to lift the arms.
• Wrinkling and excessive bagginess of the thighs. A medial thigh lift can lift the inner thighs.

Obviously all of these concerns cannot be addressed simultaneously during one operation. However, two procedures usually can be safely combined. During your consultation, your plastic surgeon will assess your anatomy as well as your own priorities to help you develop a comprehensive plan, or blueprint, for your body contouring. It is not uncommon to combine a tummy tuck with a breast lift (with or without the addition of breast implants), or a thigh lift with an arm lift, as well as other combinations of procedures.

The cornerstone of a successful approach to body contouring is to individualize treatment to your specific circumstances and goals and to ensure that you have an adequate understanding of the issues involved so that you are able to make a fully informed decision. This will help you achieve the appearance you desire with the least invasive procedure available, thus creating a mutually rewarding experience.

If you think you might be a good candidate for body contouring following significant weight loss, this article will give you a basic understanding of the procedures and the results you can expect.

The Consultation
During your initial consultation, your plastic surgeon will inquire about your medical history, prior procedures, medications, allergies, and your motivations for seeking plastic surgery. It is very important that you be thorough when providing your medical history, as this information helps to prevent complications during your care. When asked about medications, be sure to include any vitamin or herbal preparations, as these can affect your blood pressure and clotting ability. Honesty regarding your use of tobacco and alcohol is also very
important, as these may have a profound impact on your recovery period and your ability to heal following your procedure.

After reviewing your medical history, your plastic surgeon will discuss your concerns, priorities and motivations for pursuing plastic surgery, as well as your fears. After examining you, he or she will be able to off er advice and options to help you achieve the appearance you desire. He or she will explain the advantages and disadvantages of the different options you have before you.

At the completion of your consultation, you should be given a written estimate of the cost of your procedure. At this time, you will also have the option to schedule your procedure if you so choose. The decision to undergo surgery is a very important one, and the final decision should be given very careful consideration. You are also encouraged to bring your spouse, significant other, family member, or a friend to your consultation.

Where Your Procedure Will Be Performed
Most patients undergoing body contouring following significant weight loss choose to have their surgery performed in a full service hospital, and many also choose to stay overnight following surgery. Sometimes an overnight stay is required, depending on the procedure you choose and your overall health status. Alternatively, some plastic surgeons have a private duty nurse available to care for you in the comfort and privacy of your own home, or your family or friends may care for you during the early postoperative period.

Details of the Procedures
It is important to develop a comprehensive approach to your body contouring. This has evolved into several specialized techniques meant to optimize your results. These include:

Developing a clear overall strategy during the consultation process and reviewing this plan during the preoperative visit. This
plan will be reviewed thoroughly so that you have a full understanding of the procedures, incisions, and results you can expect.

Precise preoperative skin marking prior to surgery. While you are standing, your plastic surgeon will make marks on the skin identifying certain landmarks as well as the intended incisions. Not only does this provide information necessary
during the operation, but it also allows you to review the operative plan one more time with your surgeon before undergoing
the procedure.

Using various positioning techniques on the operating room table to optimize visualization intraoperatively that enables him/her to provide smooth, natural contouring from one body region to the next. Precise cutting, redraping and sculpting techniques.

Careful but considerable suture techniques to provide support to the incisions during the healing process. By using multiple layers of strong sutures beginning deep in the tissues and finishing superficially, the resulting scar is optimized and heals into an acceptable thin line. Even with this suture technique, your plastic surgeon should be able to use sutures beneath the surface of the skin that do not require removal. Not having to undergo suture removal has greatly improved patient comfort
and satisfaction postoperatively.

Type(s) of Anesthesia
Anesthesia is an essential part of any surgical procedure and must be performed safely. General anesthesia is preferred for most of these procedures and is the deepest form of anesthesia. You are asleep, feel no pain, and will not remember the procedure. This is the most common type of anesthesia used for body contouring after gastric bypass surgery because these procedures tend to be lengthy and require
full muscle relaxation for maximum tightening intraoperatively.

Intravenous sedation, called “twilight sleep,” is a combination of local anesthetic administered at the surgical site by the surgeon and intravenous sedation administered by the anesthesiologist. You breathe for yourself, but you are in a deep sleep throughout the procedure. You should feel no pain, and you will not remember the procedure. This is more commonly used for facial rejuvenation procedures. An intermediate form of anesthesia, the laryngeal mask airway (LMA), is a relatively new technique. This technique is similar to twilight sleep in that you are breathing on your own, but the method of sedation differs. With an LMA, you actually breathe anesthetic gases administered by the anesthesiologist, rather than receive intravenous sedation via your intravenous line. These anesthetic gases cause you to sleep during the procedure. At the completion of the procedure, the gases are turned off and you wake up from your sleep. You will feel no pain, and you will not remember the procedure.

The prevention of postoperative nausea and vomiting is also an important component of body contouring. To improve your overall experience and ensure you feel better faster following your surgery, a new medication has been developed that has resulted in a very low incidence of postoperative nausea and vomiting. You should be given an intravenous dose of Zofran at
the beginning of your operation. Zofran is a new drug that is currently the best medication available to prevent nausea and vomiting. This is a very important consideration to make sure that your experience is as pleasant as possible.

Your plastic surgeon will discuss all of these options with you more thoroughly at the time of your consultation, and please ask about anything you do not understand.

Depending on the combination of procedures you choose, surgery will probably last between four and eight hours. After you are properly anesthetized, your plastic surgeon will make the incisions necessary for removal of excess skin and fat. After the incision has been made, he or she gently elevates the skin and fat off of the underlying structures. For a tummy tuck, the muscles of the abdominal wall are usually tightened using strong, permanent internal sutures. Some patients have hernias in the abdominal wall, and these may also be repaired during a tummy tuck.

After removing the excess skin and fat, your plastic surgeon will re-drape the skin over the underlying structures. One or more drains may be placed beneath the incisions. These slender, rubber tubes assist in draining any fluid that may accumulate beneath the incisions and delay your healing. Your plastic surgeon may also choose to use a new product called Tissue Glue. This product helps your body heal and minimizes the fluid that may empty into your drains, allowing the drains to be removed earlier.

At the completion of the operation, a sterile dressing is applied to the incisions, and a compression garment is applied to the region of the body being treated. This compression garment helps support your incisions during healing, decreases postoperative swelling, and helps decrease any bruising that may occur.

After Your Procedure
If you are staying overnight in the hospital, you will be transported from the recovery room to your own room. You will have a PCA pump (Patient Controlled Analgesia) available so that you will only need to push a button to self-administer pain medications when needed.

Your plastic surgeon will visit you in your room the evening following surgery to check and make sure everything is going well and that you are comfortable. He or she will also visit you again the morning after surgery to change the dressings and discharge you from the hospital. You will also be provided with thorough postoperative instructions and a phone number so that you may reach your plastic surgeon directly at any time with any questions or concerns you might have.

Alternatively, if you decide to go home in the company of a private duty nurse, you will be discharged after spending one to two hours in the recovery room.

The antibiotics that were prescribed during your preoperative visit (usually Augmentin) should be taken twice daily beginning on the evening prior to surgery. Continue this medication until it is gone. The pain medication (usually Lortab or Vicodin) should be taken fairly regularly, every four hours or so, during the first twenty-four hours (when you are not asleep, of course). Most patients find that they are able to transition to Tylenol after four to five days. You should not take Tylenol AND your pain medicine, because the pain medicine also contains Tylenol and this excessive dosing of Tylenol has been known to cause liver damage.

It is not safe to drive a car within twenty-four hours of taking pain medication, as your reflexes and alertness may be altered.

You should plan to take it easy following your surgery. No strenuous activities, heavy lifting (over 20 pounds), aerobic exercises, swimming, contact sports, tennis, or golf should be planned for the first three weeks. As your plastic surgeon monitors your recovery, he or she will advise you when it is safe to resume specific activities.

You should plan to wear the compression garment for three weeks following surgery. Your plastic surgeon will remove the drainage tubes within several days following surgery as the drainage decreases to an acceptable level.

The Results You Can Expect
You will notice an improvement in your body contour immediately. However, your shape will continue to improve in the following weeks as the mild swelling subsides. You should be up and walking the day following surgery, although you will be sore for several days. You should be able to resume your normal daily activities within several days following surgery, and you should be able to resume all of your physical activities within three to four weeks of surgery. As a result of your body contouring, you should be able to look as good as you feel and enjoy your new body.

Don Revis, MD, FACS, is a double board certifi ed plastic surgeon in private practicein Ft. Lauderdale, Florida. Visit his website, www.SouthFloridaPlasticSurgery.com to read more about the various procedures described herein.