By Virginia A. Pittman-Waller, MD, MPH
Obesity is widely recognized today
as a serious health problem in
the United States. It is defined
by the Centers for Disease Control and
Prevention (CDC) as a body mass index
of 30 or greater. The BMI is calculated by
dividing a person’s weight in kilograms
by their height in meters squared.
Although not a perfect system — many
athletes qualify as “overweight” even
though they are mostly muscle with 6
percent body fat — it provides a reasonable
indicator of body fatness for most
of the population.
According to the most recent CDC
statistics released in November 2007,
more than one-third of U.S. adults were
obese in 2006, including 33.3 percent of
men and 35.3 percent of women. Almost
two-thirds of the population is either
overweight or obese. The most obese age
group is men and women ages 40 to 59,
with a rate of 40 percent and 41 percent
obesity, respectively. Within that age
group, approximately 53 percent of
black women, 51 percent of Hispanic
women, and 39 percent of non-Hispanic
white women were obese. Obesity rates
among men were slightly lower.
Surprisingly, after decades of steady
increase, the rate of overall obesity in
the United States has remained statistically
stable since 2004. Obesity rates
for women have remained fairly level
since 1999, with men catching up in
recent years.
The prevalence of obesity today has
led to a rapid increase in bariatric surgery.
According to a study published in
the Journal of the American Medical
Association in 2004, the average
weight loss for bariatric patients was
61.2 percent, with substantial health
improvements for patients with type
2 diabetes (eliminated or improved in
86 percent of patients), hypertension
(eliminated or improved in 78.5 percent),
obstructive sleep apnea (eliminated
or improved in 85.7 percent),
and high cholesterol (reduced in 70
percent). Appropriate candidates for
bariatric surgery have a BMI of 40 or
more or a BMI of 35 with one of the
conditions mentioned above.
In 2007, more than 200,000 patients
were predicted to have bariatric surgery,
according to the American Society for
Metabolic and Bariatric Surgery.
As a result of the number of bariatric
surgeries today, there has been a resulting
jump in the number of body contouring
procedures performed by plastic surgeons
on massive weight loss patients.
In 2006, more than 65,000 body contouring
procedures were performed.
Post-bariatric surgery is usually performed
12 to 18 months after the weight loss
procedure or when weight loss has plateaued
for three to six months. The typical
weight loss for post-bariatric patients
is around 100 pounds. Although the fat
is gone, the skin has been stretched so
that it now forms heavy folds, and it
drapes along and hangs from the body.
To regain a more normal physique,
post-bariatric patients often benefit greatly
from the removal of redundant skin.
The process of removing excess skin normally
requires several major operations
staged at least three to six months apart.
A typical sequence for body contouring
surgery is:
• 15 to 18 months after bariatric surgery:
a central body lift, with liposuction
of flanks and thighs;
• Three to six months later: medial
thigh lift and arm lift;
• Three to six months later: breast
reduction or augmentation with a
breast lift and trunk liposuction, if
needed; and
• Three to six months later: facial
rejuvenation.
• Total: 24 to 36 months, although not
all patients choose to have all of the
procedures.
Each surgery usually requires hospitalization,
with stays lasting up to a
few days. These are lengthy procedures
with lengthy recovery times, and the
incisions and scars are significant. The
trade-off for patients seeking improved
physical appearance and the ability to
fit better into clothing is significant
scarring, although most patients prefer
the scars to the folds of excess skin
they had before.
Body contouring surgery is essential
for optimal cosmetic results among massive
weight loss patients. The skin by
itself will never shrink to fit the shape of
the slimmer body. However, patients
must have realistic expectations. Even
though plastic surgeons can improve the
shape of the skin, we can never entirely
remove all of the loose skin.
In my practice, a candidate for body
contouring surgery must have a BMI of
30 or less. In other words, a candidate
for surgery can be overweight, but not
still obese. In a recent paper analyzing
the rate of post-operative complications
after panniculectomies, the
authors evaluated age, BMI, American
Society of Anesthesiologists (ASA)
class, specimen weight, and operative
duration. Only pre-surgical BMI was an
independent predictor for developing
post-operative complications. In
another paper reviewing complications
after abdominoplasties, the complication
rates for patients with BMIs above
30 soar to more than 200 percent
greater than the rates for overweight
and normal weight patients.
While improvement in physical
appearance is important to patients,
improvement in the psychological outlook
of most post-bariatric surgery patients is equally positive. For the first
time, many patients feel they are part
of society. Bariatric surgery patients,
however, can have special psychological
needs. During their years of obesity,
many faced ridicule, prejudice, and
rejection, leading to low self-esteem.
When the weight and excess skin is no
longer there, many have problems with
self-identity and learning to deal with
their changed life circumstances,
including attention from the opposite
sex, jealousy from spouses and obese
friends, and interference from their
own family members.
Nonetheless, despite the new
issues bariatric patients may face after
making the life-altering decision to
have post-bariatric body contouring
surgery, most patients report a substantial
improvement in their selfimage
and their quality of life.
References
American Society for Metabolic and
Bariatric Medicine
2008 Fact sheet: Bariatric surgery.
Available at http://www.asbs.org/
Newsite07/media/factsheet1_bariatric
-surgery.pdf. Accessed January 5, 2008.
American Society for Plastic Surgeons
2004, Gastric bypass surgery popularity
leads to jump in plastic surgery
procedures, according to ASPS statistics.
Press release, March 10. Available
at http://www.plasticsurgery.org/
media/press_releases/Gastric-Bypass-
Surgery-Popularity-Leads-to-Jump-in-
Plastic-Surgery-Procedures.cfm.
Accessed January 5, 2008.
Arthurs, Zachary M., Daniel
Cuadrado, Vance Sohn, et al.
2006, Post-bariatric panniculectomy:
Pre-panniculectomy body mass index
impacts the complication profile.
Paper presented at the 93rd meeting
of the North Pacific Surgical
Association, Spokane, WA, November
10–11.
Centers for Disease Control and
Prevention
2007, New CDC study finds no increase
in obesity among adults; but levels
still high. Press release, November
28. Available at http://www.cdc.gov/
nchs/PRESSROOM/07newsreleases/ob
esity.htm. Accessed January 5, 2008.
Panel Report
2006, Psychological considerations of
the massive weight loss patient.
Plastic & Reconstructive Surgery. Body
Contouring After Massive Weight Loss.
117(1) Supplement:17S-21S, January.
Pipes, Sally
2007, Brave New Diet. Washington
Post, Wednesday, December 26, p. A21.
Rogliani, M., E. Silvi, L. Labardi, et al.
2006, Obese and nonobese patients:
Complications of abdominoplasty.
Annals of Plastic Surgery
57(3):336–338, September.
Rohrich, Rod J.
2004, Obesity in America: An increasing
challenge for plastic surgeons.
Plastic & Reconstructive Surgery.
114(7):1889-1891, December.
Song, Angela Y., J. Peter Rubin, Veena
Thomas, et al.
2006, Body Image and Quality of Life
in Post Massive Weight Loss Body Contouring
Patients. Obesity
14:1625–1636
Wu, June K.
2006, Body contouring after bariatric
surgery is critical for optimal cosmetic
results. MedGenMed 8(2):77.
Available at http://www.pubmedcentral.
nih.gov/articlerender.fcgi?tool=pu
bmed&pubmedid=16926816.
Accessed January 5, 2008.
Virginia A. Pittman-
Waller, MD, MPH
is a plastic surgeon in
private practice in San
Antonio. She received
her MPH from the Yale
School of Medicine and
her MD from The
University of Texas Medical School at San
Antonio. She trained in general surgery at
University Hospital in San Antonio and
in the UMDNJ affiliated program at
Morristown Memorial Hospital in
Morristown, NJ, which has one of the
largest bariatric surgery programs in the
country. She completed her plastic surgery
residency training in the Methodist Hospital/
St. Joseph Hospital program in Houston.
