Post bariatric surgery reconstruction emerged as new subspecialty of plastic surgery in the last few years. This constitutes a group of procedures that are utilized to tighten excessively loose skin, frequently after massive weight loss. A smaller group of patients, who are normal weight and have never been overweight, will present with loose enough skin to warrant surgical tightening in the inner arm, posterior trunk, buttocks or thigh regions.
Abdominoplasty, or a “tummy tuck,” is designed to correct a protruding abdomen resulting from weak abdominal muscles, weight gain or pregnancy. Obesity and aging cause the skin to lose its elasticity. These conditions may not respond well to diet or exercise if the skin and underlying muscles have been stretched.
With abdominoplasty, the abdominal wall muscles are tightened and excess fatty tissue and skin are removed to improve the body contour. The goal is a narrower, flatter abdomen. Realistic expectations are important. Abdominoplasty is not a substitute for weight loss.
Your doctor considers age, obesity and smoking habits when evaluating a candidate for this procedure.
Before Surgery
We will take a complete medical history and conduct a careful examination to evaluate your general, overall health. Ideally, the abdominoplasty patient has no health problems, and wishes only to remove an excess deposit of fat or loose abdominal skin. Patients on a weight-loss plan should be close to their target weight before having the operation. Women planning future pregnancies should delay abdominoplasty, as pregnancy may promote further abdominal stretching.
Photographs will be taken before and after surgery.
Antibiotics will be prescribed prior to surgery to prevent infection. To minimize the possibility of excess bleeding, you will need to avoid taking drugs containing aspirin. You will also be advised to bathe with an antiseptic soap for several days prior to surgery.
The Procedure
Abdominoplasty is performed using general anesthesia. You may be given medication beforehand so you will feel relaxed. The surgery may take 2-5 hours, depending on your overall condition. You may be released after a few hours, or you may require a couple days of hospitalization.The procedure is most commonly performed by making a U-shaped incision below one hipbone, across the pubic area and under the other hipbone. A second incision is made around the navel. The skin is then separated from the abdominal wall and lifted up to the hipbone, exposing loose tissue covering the abdominal muscle.
Loose, stretched out muscles are tightened with sutures, and excess skin and fat are removed. The skin is lowered over the abdomen and the navel is reconstructed. The incisions are then sutured together. Drains are often inserted to eliminate fluid buildup, and firm elastic bandages are applied to the area.
Recovery: What to Expect
You may experience some discomfort immediately following surgery that can be controlled with pain pills. Some swelling is normal. You will be given special instructions for showering and changing your dressings until the surface stitches are removed in 5-7 days. You may also be required to wear a support garment.
The speed of recovery depends on your physical condition prior to surgery; those with stronger abdominal muscles usually recover faster. Allow at least 2-4 weeks to recuperate before returning to work. Some scarring is also normal. It often takes 9-12 months before the scars begin to fade.
Though the recovery period is longer than that of other cosmetic procedures, the rewards are great for a patient previously distressed by a protruding abdomen. Those who follow a proper exercise routine and healthy diet will benefit from abdominoplasty the most.
Body lift, or belt lipectomy, is performed to remove the excess skin and fat that exists on the body as a result of age or extreme weight loss. The body lift is performed on the lower torso and upper legs and involves the belly, hips, back, buttocks and outer thighs. People who have excess skin or fat in all of these areas may benefit from the body lift procedure.
This procedure involves a tummy-tuck combined with a circumferential excision of excess tissue from around the entire trunk while elevating the buttock and outer thighs. Obviously, this is a very extensive procedure requiring longer operative times and recovery than just a tummy-tuck. A lifting effect is obtained at the level of the buttocks, the outer thighs as well the abdomen and flanks.
A thigh lift removes loose skin from the thighs. Weight loss is the usual cause of extensive redundancy of skin in the inner thigh area. Constant rubbing of this redundant inner thigh skin can result in irritation and infection. Appearance and comfort are improved by the thigh lift procedure.
This procedure involves resection of redundant tissue of the inner thigh using incisions that parallel the groin crease. The thigh lift is usually performed on the inner surface of the thighs but can include the outer thigh area and buttock if indicated.
An arm lift, or brachioplasty, is a procedure to remove excess fat and skin of the upper arm. Aging or weight loss can cause the upper arm skin to become loose and sagging. An arm lift serves to remove excess skin and fat which reduces the circumference of the upper arm. The extra skin and fat are removed through an incision along the inner aspect of the upper arm. This incision is placed in order to best tightened the tissue but the incision must also be well hidden.
Liposuction is a very common, popular procedure. It is designed for the permanent removal of fatty tissue, commonly referred to as “cellulite.” It is an elective procedure that allows the plastic surgeon to remove undesirable, subcutaneous fat in isolated areas that do not respond to diet and exercise. These areas include the hips, thighs, abdomen, knees, ankles, face, neck, and arms.
Liposuction is most successful in people with good skin tone who have fatty deposits. It is not a treatment for obesity. If weight gain occurs following liposuction, the fat will be deposited in areas that have not been treated. The procedure can be repeated, if necessary. To maintain the safety of the procedure, there is a limit on how much can be done at one time.
A variety of factors can affect the results: Physical condition, genetic makeup, diet, exercise, smoking, alcohol intake, and skin elasticity.
Body contours made irregular by fat can be improved by this procedure; it cannot correct contours that are irregular for other reasons, such as muscle weakness or hernia. However, combined with other procedures, liposuction can correct these other deformities with good results.
The Procedure
Liposuction is done under general anesthesia on an outpatient basis. The surgeon makes small (less than 1/2 inch), discreet incisions in the areas to be treated. A cannula is inserted in a small incision and attached to a suction machine. The procedure may take an hour or more, depending on how many areas are involved.
Recovery
Recovery from liposuction is relatively easy. Expect a fair amount of swelling and bruising in the following two weeks. You will wear special garments provided to apply pressure, minimize swelling and provide support while healing. These garments also assist in retraction of the skin. Stitches will be removed in a week to 10 days.
Results are recognizable almost immediately and will continue to improve as swelling subsides. The day after surgery you should be up and walking around. Increase your activity daily until full activity is resumed at 2-4 weeks. You will be ready to return to office work in 3-5 days and more active employment at 10-14 days. Avoid the sun until all bruising has subsided. A sunscreen should be used routinely; it is easy to get sunburned during recovery because of decreased sensation.
The results of liposuction are permanent. If you were to gain a large amount of weight you might note rippling in the treated areas, depending on your skin elasticity.
Possible Complications
As with any surgical procedure, complications can occur. Cosmetic complications include contour irregularities, skin discoloration, asymmetry, scar tissue, tape burns, collection of blood or fluid under the skin. Uncommon complications include loss of sensation, skin breakdown, fat embolism, serious infection or shock. Bleeding does occur during liposuction. There is a limit to the amount of fat that can be safely removed in a given procedure.
Following liposuction, the scar will go through a maturation process–during the first 8-12 weeks they may be red and possibly raised. The scars will mature over 6-2 months and become pale, flat and soft. You may experience numbness, burning, tingling around the incision site. These symptoms are almost always temporary.
Please let us know if you are prone to keloid scars.
Post weight loss patients also frequently are left with loose neck skin or jowls, and these procedures are covered in the face lift section. This section will focus on procedures utilized to address skin laxity along the inner arms, upper and mid back regions, buttocks and thighs.
Twenty five years ago, it was rare to have a patient walk into a plastic surgeon’s office after substantial weight loss. But these days, we routinely see patients who have lost in excess of one hundred pounds. About three quarters of the massive weight loss patients we see did so with the assistance of bariatric surgery–such procedures have been designed to either decrease the size of the stomach pouch or some variety of “bypass” which shunts food down the intestines quicker without absorbing as many calories. With the advent of laparoscopic surgery and the more sophisticated bypass and stapling techniques, the efficacy, safety and popularity of such “bariatric” surgery has sky rocketed. This year over 140,000 bariatric procedures will be performed in the United States, and the numbers keep climbing higher each year as more centers with expertise in such procedures open up. But a good quarter of the weight loss patients we see achieved their results the good old fashioned way, by altering their diets and by exercising regularly!
Most patients who have lost a lot of weight have multiple areas to address. These body contouring procedures can be combined to address multiple areas, with certain limitations and exceptions. It is not safe to address the inner thighs and abdomen at the same sitting because of blood flow interruption to the pubis and strip of skin between the inner thighplasty scars and abdominoplasty or belt lipectomy scars. But with either procedure, it would be safe to address, for example, the inner arms or breasts. Such procedures may also be combined with non-skin tightening operations such as liposuction, eyelid surgery or other procedures. Your overall health and age will also help determine how much surgery you can tolerate in one day. But even if you are in perfect health, it is unwise to electively schedule procedures that are designed to be longer than six hours in length because after that time, your chance of developing a blood clot in your legs or other complications will become more likely.
The operation is directed toward an improvement and will not in any way give you complete obliteration of all folds, laxity and stretch marks. You must accept the judgment of your plastic surgeon and realize that he will remove as much as is safe and suitable. Particularly in patients with thicker fatty layers or marked skin excess, it may be desirable to return for additional skin excisions to obtain an optimal result.
The type of skin, degree of elasticity and age of the patient all influence the overall result that is obtained. The operation should not be undertaken if the patient’s weight is not stable or if a patient has not made a commitment to themselves to keep the weight off in the foreseeable future. While it is not necessary for the patient to reach a certain weight before surgery may be performed, it is desirable that the patient’s weight be stable for at least six months prior to surgery and that the patient be at a weight he/she feels can be maintained after the procedure.
A common question is, “How long will the results of this procedure last?” This is impossible to state. Factors affecting the length of the result include age at the time of operation, physical conditioning afterward, type of skin, and alterations in weight. In general, it is not necessary to repeat these procedures after an optimal result has been achieved. Should the patient wish to repeat the operation, regardless of the length of time since the initial operation, the degree of laxity or fatty excess remaining, and each patient will be responsible for the cost of a subsequent procedure.
POST-OPERATIVE CARE:
Adequate pain medication will also be prescribed. All patients, who go home on the day of surgery or the next morning, will find that an assistant at home is a necessity for the first three days or so. High bulk foods are highly encouraged and laxatives may be necessary to prevent straining associated with constipation.
The patient will be encouraged to walk as much as possible at home after surgery as this will reduce the possibility of pneumonia or of clots forming in your calf veins. It will be necessary to avoid flexing the hips after thigh or buttocks procedures for the first few weeks to prevent excess tension on the suture lines.
The patient will usually be allowed to shower after the drains have been removed, but soaking in a bathtub is to be avoided for two weeks. Wounds are generally closed with buried sutures. The incisions are covered with surgical tapes, which are to stay in place for the first two weeks. These tapes will not fall off with gentle showering as long as you refrain from rubbing them with face cloths or towels.
Your first post-operative visit will generally be scheduled two to four days after surgery at which time the pain pump catheters will be removed, or four to six days later if you choose not to have the
pain pumps. The drainage tubes will be removed at a subsequent visit, when the drainage has essentially stopped. You will be required to have someone drive you to the office for your first, and perhaps second, visits. Most patients find that they can gradually increase their activity levels thereafter. You may drive a car with caution, wearing a safety belt, beginning 48 hours after your last pain pill or sedative, if you feel comfortable and physically able to do so.
SOCIAL ACTIVITY:
Social activity should be limited while the patient is uncomfortable. Lifting anything that causes discomfort should be limited for approximately four to six weeks to allow the tissues to heal properly. Strenuous activity should be avoided during the initial six to eight weeks. Basically, most patients find that they can return to normal activity as the discomfort of the operation fades away. Office work can usually be resumed within 1-2 weeks of surgery, but the patient should expect a six-week delay before returning to physical labor or strenuous exercise. It will take longer than a year for scars to fade and the abdomen to feel relatively normal. The lower abdominal skin may feel numb forever and completely normal feeling is not to be expected.
POSSIBLE COMPLICATIONS:
Serious complications after an abdominoplasty are relatively uncommon. However, there will be a long scar (usually, but not always, within the bathing suit line) extending from hip to hip. The scar may remain itchy, painful, thick, or otherwise unsightly. It is unusual, but possible, for areas of fat to liquefy and drain through the incision for many months. As with any abdominal procedure, it is also possible for a suture or staple to become infected and to erode through the skin years later.
Fat is poorly vascularized, does not have much tensile strength and does not contribute significantly to holding the wound together. In this type of surgery, particularly involving the trunk or lower extremities, there is a very high incidence of portions of the incisions pulling open. Occasionally the wound margins can be resutured, but frequently the safest course of action is to leave the wound open and allow it to heal by contraction and secondary intention. This might take a few months to occur and may necessitate wound care at home from a visiting nurse. Should this occur, it may be necessary to perform a secondary scar revision a year or so later. As with all complications or desired secondary procedures, each patient will be responsible for the cost of a subsequent care or procedures.
It is common to experience swelling of the hands with a brachioplasty, or of the ankles following thigh or buttocks surgery. Such swelling is self limiting. Some areas of numbness will be evident following body contouring surgery. Usually, most of the feeling will return within about a year but some patients will experience areas of permanent numbness.
One of the most common problems after body contouring is a persistent collection of serous fluid under your skin after the drains have been removed. Should this occur, this fluid will be aspirated by your surgeon with a needle during your post-operative visits. Such drainage always stops eventually (but may persist for more than a month) and usually does not affect the final results. If wound problems develop, it may take several weeks or even months for healing to take place and the patient will be required to wear dressings over the open wound. Because of the extensive skin
And fat undermining, areas of skin may die and slough, or even require surgical debridement or a skin graft. Rarely, phlebitis may develop in leg veins and even more rarely, blood clots could travel to the lungs, potentially leading to a fatal complication.
Perfect symmetry does not exist before or after body contouring surgery. Scars will never be identical from side to side. As mentioned earlier, it will take longer than a year for scars to fade.
Secondary procedures may occasionally be desirable to revise scars or to remove additional tissues. The patient will be responsible for all costs associated with secondary surgical procedures.
It is not possible to list every conceivable complication. As with any operation, there could be potential complications, which could even be fatal. The foregoing is not intended to frighten or upset you but to enable you to make your decision with an understanding of some of the involved risks.
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