Shape Up

Created on 25th September 2008

Weight loss surgery is a fast growing trend in the UK. Consultant plastic surgeon Mr James McDiarmid looks at what are the options after you've lost the weight

Obesity is becoming increasingly common in our society. The frenetic pace of modern life leaves little time to set aside for regular exercise and readily available inexpensive junk foods can become a far easier and more convenient option than a traditional healthy diet.

The health risks associated with obesity such as diabetes, high blood pressure and heart disease are a major concern and for these reasons many adults seem to spend most of their lives on a diet of one sort or another.

Although many patients manage to lose large amounts of weight through dieting and exercise alone, increasing numbers of patients are now resorting to weight loss or bariatric surgery.

Bariatric surgery

This is usually performed by general (gastrointestinal) surgeons with a special interest in this condition. The main options for weight loss are laparoscopic gastric banding (lap band) and gastric bypass.

Laparoscopic banding is the more frequent option and involves using keyhole surgery techniques to wrap an inflatable band around the stomach, the contents of which can be adjusted to make the band tighter or slacker by means of a simple injection through the skin into a subcutaneous port attached to the band. This is a less invasive procedure than gastric bypass surgery and has the benefit of adjustability.

Gastric bypass surgery is a more involved procedure during which part of the small intestine (the most absorbent part of the gut) is bypassed leaving only a small length of bowel to absorb nutrients. This is more major surgery which involves cutting the bowel and joining it back together. Although the chronic malabsorption it causes has the effect of producing weight loss the chronic lack of nutrients can make the healing process after surgery more challenging.

Recontouring surgery
Several months after bariatric surgery once the patient's weight has stabilised it is possible to consider recontouring surgery.

Recontouring surgery is best performed when several stones of weight have been lost as the skin has usually become so stretched that it has exceeded its elastic limit and rather than shrinking it simply hangs down in an unattractive way, potentially causing problems with hygiene and comfort.

Recontouring surgery post weight-loss is most usually thought of in terms of just the abdominal area, but in reality an entire raft of procedures can help patients to gain a better contour in the arms, thighs, buttocks, face, neck and breasts.

Body lift vs abdominoplasty
Taking the abdomen first, there are big differences between the way the abdominal skin expands during pregnancy and in obesity. In pregnancy the majority of the skin expansion occurs between the pubis and the umbilicus (belly button). Striae (stretch marks) sometimes appear and usually affect this area but can occasionally spread to the area above the umbilicus. A variant of a conventional tummy tuck or abdominoplasty (with or without liposuction) is a very effective way to deal with post-pregnancy skin excess.

After massive weight loss however, the abdominal tissues have a different pattern of redundancy to the postpregnancy scenario. The excess skin often reaches farther around the circumference of the trunk and can even go all the way round. The upper abdomen is also very often left with excessive loose skin and also the mons pubis can be enlarged and heavy. Dealing with tissue excess most effectively after massive weight loss requires an entirely different approach such as body lift surgery and a conventional post-pregnancy tummy tuck is often not up to the job.

The most fundamental issue here is that a post-pregnancy tummy tuck is completely different to a post-weight loss body lift. A body lift is a circumferential procedure which involves removal of excess tissue from the entire circumference of the body. It also includes extensive liposuction, recontouring of the buttocks using flaps of tissue to restore fullness (these are often flaccid and empty after weight loss), a lateral thigh lift and a very extensive abdominoplasty (tummy tuck).

Reversed abdominoplasty
In cases where there is extreme tissue excess then a reversed abdominoplasty (lifting upwards rather than downwards) may be necessary after weight loss.

Augmentation mastopexy
After weight loss the breasts often benefit from filling with an implant as well as undergoing an uplift. This procedure can sometimes be performed safely in one go but may need to be staged in certain cases (i.e. uplift first then implant later) for safety reasons.

Face and neck lift
Massive weight loss also presents unique challenges due to disproportionately large deposits of skin and fat in the neck area that necessitate removal. Often extensive work to the platysma (neck) muscle is necessary in order to restore a satisfactory contour.

Conclusion
Through constant refinement of techniques and the exchange of ideas between specialists our understanding of the unique challenges that recontouring surgery after massive weight loss presents to the patient and surgeon become clearer and the patient’s journey will become safer and better.  CSMUK