How to Maintain the Results of Plastic Surgery After Massive Weight LossAugust 31, 2020
Maintaining Results of Plastic Surgery After Massive Weight Loss
Massive weight loss (MWL) is defined as 50% or greater loss of the excess weight. While massive weight loss construes many positive benefits in one’s heath, lifestyle, and well-being; there are also problematic excesses of skin that are left behind. When researching a plastic surgeon, make sure the surgeon is experienced in performing plastic surgery after massive weight loss.
With massive weight loss, the reduction in fat leaves excesses of skin, which can be both deforming and medically problematic. Excess skin creates folds and creases, which can harbor bacteria and cause skin irritation. Removing the excess skin and tissue is the fundamental goal of plastic surgery after massive weight loss.
Common areas where skin excess manifests itself are:
- Neck and face
- Breasts: male or female
- Arms and Armpit area (axilla)
- Upper back and bra strap area
- Abdomen, Flanks, and Lower Back
- Hips and Thighs
With massive weight loss, any one or combination of these areas may affect a particular patient. There are well established and researched procedures designed to address any of these areas. However, because these procedures involve large incisions; and often times removal of large amounts of tissue, safety is paramount in designing a plan for each individual patient.
Plastic Surgery After Massive Weight Loss
For elective surgery, safety guidelines are well established and should be strictly followed. Before surgery, patients should ideally have a Body Mass Index (BMI) of less than 30. Patients with a normal BMI have better wound healing and a lower incidence of complications which could compromise both patient safely and the aesthetic result.
Patients should be in good health and any comorbid conditions, such as diabetes or hypertension, should be well controlled. Patients should not smoke or use nicotine products for several months before and after the procedure. Patients should avoid medications, which could cause bleeding or medications such as diet pills, which might cause issues with anesthesia.
It is recommended that patients see their primary care physician for routine blood work and an exam prior to elective surgery.
The surgical procedure should be less than 6 hours in duration as prolonged anesthesia beyond 6 hours poses risks for outpatient procedures. A complete blood count (CBC) should be normal before surgery, and blood loss should be estimated and carefully monitored during surgery. Liposuction is commonly used with these procedures, the amount of fluid introduced (tumescent fluid) and removed (liposuction aspirate) should be monitored, controlled, and included in blood loss estimates.
Patients should have deep venous thrombosis prevention measures in place before and throughout surgery such as compression hose and sequential compression devices. Antibiotics should be given before surgery and if necessary during surgery to prevent infection. After surgery, patients should be carefully monitored and kept overnight for observation if necessary.
Following these guidelines, the sequence and number of procedures done in a single setting will vary from patient to patient and doctor to doctor. However, the above guidelines should be strictly followed. Many surgeons will have a standard protocol for their procedures such as breast and arms, followed by the lower body, followed by face and neck. Other surgeons will leave this up to the patient and do those procedures the patient views as the most critical first.
Common Procedures to Remove Excess Skin & Tissue
Head and Neck: Facelift (rhytidectomy) and Necklift (platysmaplasty)
A facelift and necklift are done using well-hidden incisions below the chin and around the hairline and ear. Skin is undermined, advanced, or tightened, trimmed of excess, and sutured. Deeper layers of the face called the Submuscular Aponeurotic System or SMAS are also treated to tighten underlying soft tissue. Excess fat is removed from the neck and excess neck skin is removed from behind the ears.
Arms and Armpit Area (Axilla): Brachioplasty or Extended Brachioplasty
Excess skin and fat on the upper or proximal arm is removed with a brachioplasty where an incision is made on the inner aspect of the arm from the elbow to the armpit area or axilla. Excess tissue is removed and the incision is carefully closed over a drain tube, which is usually removed in several days. If necessary, the arm excision is extended into the armpit area or axilla where excess tissue in this area and on the lateral chest is removed.
Upper Back and Bra Strap Area
This area is prone to wide scars and oftentimes overlooked. These incisions are variable depending on the surgeon protocol but can be positioned either vertically or transversely across the back.
Abdomen, Flanks (Love Handles), and Lower Back: Abdominoplasty, Flankplasty, or Circumferential Abdominoplasty or Lower Body Lift
Abdominoplasty is commonly known as a tummy tuck. The tissue from the belly button to the pubic area is removed and the remaining tissue undermined at the level of the abdominal muscles to the rib cage. The abdominal muscles (rectus abdominus) are tightened and excess tissue is removed. The remaining tissue is advanced to meet the pubic area tissue and then carefully sutured together.
In many cases, an abdominoplasty is combined with liposuction of the flanks to sculpt the waist. If a large overhang of tissue is removed with minimal undermining, then the procedure is typically referred to as a panniculectomy.
The incision can be extended laterally to include the flanks or love handle areas. When this is done the procedure is typically referred to as an extended abdominoplasty.
In many cases, the excess tissue will extend onto the lower back causing excess lower back skin and drooping or ptosis of the buttocks. In this case, the incision can be extended circumferentially or all the way around the waist, in a procedure known as a circumferential abdominoplasty or a lower body lift. This procedure not only removes excess skin and tissue but also lifts the buttocks and lateral thighs.
Buttocks: Buttock Lift and/or Autologous Fat Grafting
With massive weight loss, the buttocks are affected in two ways. The loss of fat results in droopiness or ptosis of the butt with a flattened appearance without projection or curve. This is typically corrected by lifting the butt during a lower body lift or using liposuction of remove fat from one area and placing it into the butt to restore volume: autologous fat grafting. In many cases, both lifting the butt and filling with fat graft are necessary to achieve an optimal result.
Hips and Thighs: Thighplasty with or without Liposuction
Hips and thighs are often excellent areas for liposuction where fat is removed with a suction device through small access incision. However, liposuction will not remove excess skin or tighten skin. Excess thigh skin is typically removed with a medial thigh lift or thighplasty where an incision is made in the groin crease and if necessary extended down the inner thigh as far as necessary. Tissue is undermined, advanced, trimmed of excess, and carefully closed over a drain tube.
The first step in achieving the best possible long-term result is healing the incision and recovering from the procedure. Patients will need to walk or ambulate several times daily to prevent blood clots from forming after surgery.
Deep breathing will help to expand the lungs and prevent post surgical fever due to atelectasis. Each surgeon will have a different protocol but in general incisions should be kept clean and covered with sterile gauze. Antibiotic ointment is often recommended in the early stages. Compression garments may need to be worn for several weeks. These garments help to mold and shape the body as it heals, prevent swelling, and apply pressure so that fluid does not build up below the skin.
Optimizing the quality and appearance of the resulting scars is paramount to achieving an optimal outcome. Again, each surgeon will have a protocol for scar management.
After the initial wound healing phase, there are several options. Medical grade scar care cream can be prescribed and applied daily for an extended period of time. Alternatively, silicone sheeting can be applied over the scars.
Scars will typically take a minimum of 6 months to progress through the 3 phases of wound healing: Inflammatory phase, proliferative phase, and maturation phase. Once healed, scars can be further improved with resurfacing options such as microneedling, dermabrasion, or laser therapy.
Long-Term Results for Plastic Surgery After Massive Weight Loss
The surgical outcome will be apparent at 6 months and should be evaluated with the surgeon using standardized photography. Even with the best surgical outcome, the results will only be as good as the post-surgery maintenance program.
Many areas such as the face, neck, and breasts are susceptible to gravitational aging and will sag and droop with time. A typical facelift, for example, will last about 10 years. Other areas such as the abdomen will maintain their appearance better so long as weight is stable.
Skin quality is a very important factor and varies from patient to patient. In many cases, weight loss patients will have very thin and inelastic skin that is prone to stretching, sagging, and poor scarring. In these patients, maintaining good skin health with hydration, moisturization, avoidance of sun, and diet is critical.
Maintain a Stable Weight
As stated above, a stable weight is critical which is one reason why it is important to wait until the Body Mass Index is below 30 before surgery. In some cases, with heavier patients, weight loss after plastic surgery results in loose skin and recurrence of the deformity. In other cases, patients may gain weight after surgery, which would compromise the result.
Maintaining a stable weight can be difficult even with surgical procedures such as a gastric bypass or a gastric sleeve. Dieticians can be very helpful in recommending a healthy and well-balanced diet. It is helpful to choose a diet that can be maintained over time as part of a healthy lifestyle rather than a fad diet which is difficult to maintain.
Diet, combined with proper exercise, is far superior to just diet alone for maintaining weight. It is recommended to exercise for at least 30 minutes, four times per week. Exercise should be divided between cardiac based exercise and muscle building exercise.
Examples of cardiac exercise are walking, cycling, jogging, or the use of exercise equipment such as an Elliptical trainer, Stair Master, Spin Class, or rowing machine.
Muscle building exercise centers on stretch and flexibility training, such as yoga, core exercises, weight lifting, or resistance training. It is always advisable to consult with your primary care doctor before beginning an exercise program and getting some introductory instruction from a personal trainer on proper form and technique so as to avoid injury.
In conclusion, the weight loss journey is long, multifaceted, and mentally and physically taxing. The final stage is not complete once you’ve healed from plastic surgery.
Maintaining the results will require a lifetime of dedication. The reward of a fit, trim, and healthy body will hopefully make your journey well worth the effort.
ABOUT THE AUTHORJohn Burns, MD is a Board Certified Plastic Surgeon with advanced fellowship training. Dr. Burns is a surgeon at Dallas Plastic Surgery Institute and believes in a systematic and precise protocol for incorporating plastic surgery into the weight loss and maintenance lifestyle. The goal of plastic surgery should be to completely restore a person to their preobese body shape.