May 9, 2008 (San Diego) -- For patients who lose massive amounts of weight -- 100 pounds or more -- the battle isn't over once they reach their goal weight. They're left with hanging skin and excess fat and may opt for body contouring surgery, which can include multiple operations.
The procedures have improved as surgeons have gained experience, learned when to combine liposuction and excision, and learned how to reduce complications, say surgeons who spoke at a panel on body contouring surgery at the annual meeting of the American Society for Aesthetic Plastic Surgery in San Diego.
Body Contouring: The Goal
"These patients come in and say, 'I've lost the weight and still feel fat,'" says plastic surgeon Al Aly, MD, who spoke at the meeting. His goal for these patients, he says, is to help them shed the "fat" stigma by eliminating as much excess skin and fat as possible.
That typically translates to performing a variety of procedures that may combine liposuction and surgery. Large amounts of loose and heavy folds of skin can be left around the arms, thighs, breasts, buttocks, face, and abdomen.
One of the most common surgical procedures to improve appearance is a lower body lift, in which an incision is made around the lower trunk and the thighs, abdomen, and buttocks are lifted. Nearly 13,000 of these were done in 2007, according to the American Society for Aesthetic Plastic Surgery.
Because buttocks tend to flatten out with extreme weight loss, a buttock augmentation may be done. A tummy tuck is sometimes done, too. More than 5,000 buttock augmentations and more than 185,000 tummy tucks were done in 2007.
Some patients also have an upper body lift, sometimes including breast augmentation to restore lost volume and an arm lift to improve droopy-looking skin there.
Body Contouring: Refinements and Discoveries
As doctors have gained experience, Aly says, they've gained control over the position of the scars from the surgeries, so they are less noticeable.
The body contouring procedures can be accompanied by complications, including bleeding, infection, tissue death, abnormal scars, and formation of a seroma -- a mass or lump that results from fluid buildup in an organ or tissue.
Doctors now know that certain patients are more apt to have those complications. "The higher the BMI [body mass index], the higher the complications and the worse results," says Aly.
For patients with the highest body mass index, "I tell them there is a 100% chance of complications."
The trend, says Aly, is away from performing many procedures at one time. "We feel very strongly that multiple, smaller procedures are safer than larger ones," says Aly, who has worked as a consultant for Ethicon, which makes surgical instruments, and other device manufacturers.
Another trend is to use two teams of surgeons, says Dirk Richter, MD, a plastic surgeon in Wesseling, Germany, who also spoke at the meeting and has been a consultant for Ethicon Endo-Surgery, maker of surgical instruments, and other companies.
Instead of augmenting the flattened buttocks, such as with an implant, he moves fat from the outside of the thighs to build them up. "It's easy to bring it up" to the buttocks area, he says.
Body Contouring: When Less Is Enough
Despite the variety of procedures that can be done to remove the excess skin and fat after massive weight loss, sometimes "less can be OK," says Sharon Giese, MD, a New York City plastic surgeon who also spoke about body contouring. And fewer procedures are sometimes acceptable to patients, she finds.
There's no one right procedure or procedures for these patients, she says. Ideally, she would prefer to do the body contouring surgery on those whose body mass index is below 30 (and no longer considered obese). But she will perform appropriate surgeries on patients who have lost great amounts of weight but still have a BMI of up to 35, she says, if they don't have other medical problems.
For some, liposuction alone is satisfactory to them, without the body lift, she says. And, she adds, the liposuction motivates many patients to pay closer attention to diet and exercise. "Many lose more weight after the liposuction."