As obesity has become a national epidemic, the number of people losing massive amounts of weight has grown, too. Some shed the pounds with diet and exercise. Others do it with bariatric surgery. Between 1998 and 2003 alone, the number of these surgeries grew by a remarkable 740%.

Losing weight, whether through surgery or diet and exercise, produces health benefits, as we all know. But losing a significant amount of weight leaves a patient with a different kind of appearance problem: hanging folds of loose skin and tissue. For some, the solution is another type of surgery called body contouring.

Sizing up the problem
One definition of massive weight loss (MWL) is a loss of 50% or more over an 18-month period. Despite a successful weight loss, skin that was stretched as the person gained weight will never shrink back to a normal contour. A patient with MWL also has poor skin tone and significant skin laxity. Many such patients who seek help say that they still look and feel fat.

Typically, these patients have trouble finding clothes that fit because their weight loss isn’t uniform over the body. Hanging folds of skin or tissue create moist areas that cause irritation and rashes (intertriginous dermatitis), especially during warm weather. Patients who thought they’d be more active after losing weight find that flabby areas jiggle with activity, making it difficult.Candidates for contouring

Most body contouring procedures are elective. Screening includes a medical history and lab work at least 4 weeks before surgery. If a candidate for body contouring has a medical condition that could affect the surgical outcome—for example, diabetes or a cardiac or pulmonary problem—he or she may need clearance for surgery from a medical specialist.
Before the procedure, the surgeon encourages the patient to lose as much weight as possible to achieve the best possible results. The patient’s weight should be stable at a level that can be maintained for at least 6 months before body contouring.

The surgeon or nurse evaluates the patient’s nutritional status, too. After extreme dieting or bariatric surgery, patients may have malabsorption or an inadequate intake of recommended nutrients, which can cause anemia, protein deficiency, B12 deficiency, low calcium and potassium levels, or impaired absorption of critical vitamins and minerals needed for wound healing. A smoker must quit smoking for 2 weeks before surgery and until the wounds are healed.

The patient’s coping abilities and expectations must be assessed. A candidate must have realistic expectations and be willing to accept significant scars. In some cases, the surgeon may request a psychiatric clearance.

Types of contouring procedures
Several surgical procedures can be used to contour the body:

• lower body lift
• upper body lift
• thigh reduction
• face-lift.

An experienced plastic surgeon considers all aspects of body contouring and plans the surgery needed to help the individual patient achieve the desired results. Remember, the pattern of weight loss varies widely among patients as do the amount and thickness of hanging abdominal skin. In some patients, hanging abdominal skin may reach the thighs.

Patients may have rolls of skin or tissue on their backs. Some patients retain weight in their thighs; others are satisfied with their legs. During the initial consult, the surgeon asks which area troubles the patient the most, in case the patient needs more than one surgery.

A word on liposuction: Depending on the circumstances, a surgeon may use liposuction to remove fat. But the skin laxity and poor tone caused by MWL will not allow the skin over a liposuctioned area to shrink and adhere to the new contour.

Lower body lift
Most plastic surgeons prefer to perform the lower body lift first because it can affect other body areas, such as the inner thighs. The lower body lift creates a flatter, tighter abdomen, reduces drooping of the mons pubis, provides an upward pull of the lateral thighs, creates a more defined waistline, reduces hips and flanks, provides a buttock lift, and eliminates excess skin and tissue on the lower back.

The surgical incision goes completely around the lower body because a “tire” of excess skin and tissue is removed. Liposuction may be used to improve the contour in areas next to the incision, such as the lateral thighs.

Upper body lift
The upper body lift addresses several areas. In both men and women, drooping breasts can be lifted. A man receives a flatter chest. A woman may also receive breast implants to provide volume and projection. The surgeon can also reduce sagging upper arms and remove excess skin or tissue on the lateral chest and upper back.

Some patients require only brachioplasty to reduce hanging loose skin and tissue of the upper arm, often called “bat-wing deformity.” The incision may need to start below the elbow and extend along the inner arm through the axilla and onto the lateral chest to obtain the best results.

Thigh reduction
A surgeon may be able to reduce the thighs by removing only a horizontal ellipse of skin and tissue at the top of the inner thigh. Typically, however, the surgeon has to make a long incision from the groin to or below the knee along the inner thigh to remove enough skin and tissue.
Some patients retain a large amount of fat in their arms or thighs even though they have lost lots of weight. These patients need liposuction before undergoing surgery for skin resection.

Face-lift
Weight loss can make the face gaunt and make the patient look older. Face-lift surgery addresses the lower third of the face from the bottom of the nose to the neck. The surgeon tightens sagging jowls and neck skin and provides more definition between the chin and neck.

Preparing for body contouring
After surgery is scheduled, the patient receives a packet of information, including preop and postop instructions, and forms, including the consent form, so the patient and family can make preparations at home. The preop information also includes a list of drugs and nutritional supplements that the patient can’t take within 2 weeks of surgery.

Either 1 or 2 days before surgery, the surgeon meets with the patient to answer questions and reinforce patient teaching. Usually, patients are anxious before surgery and need reassurance. During this visit, the surgeon or nurse updates the patient’s history and examines the patient. Depending on the surgeon’s preference or the facility’s requirements, more lab work may be ordered.

During the preop visit, the surgeon may mark the body for contouring because there’s more time than on the day of surgery. These markings provide the pattern for how much skin and tissue can be removed safely. Also, there’s the matter of privacy. A patient may be embarrassed to stand nude in front of one or two plastic surgeons for a prolonged period. The privacy of the office and the support of the plastic surgical nurse help ease the embarrassment.

Ensuring a safe procedure
To ensure patient safety, the surgical team takes several steps. Nurses apply sequential compression stockings or boots. If the procedure will take a long time, a team member inserts a urinary catheter.

Because large areas of body surface may be exposed, a nurse makes sure the room is warm, and the anesthesiologist monitors the patient’s temperature. If necessary, a team member applies a hyperthermia blanket. Nurses also apply electrosurgical pads and pressure-relief padding.

During some body contouring procedures, the team changes the patient’s position. A lower body lift, for example, may start with the patient supine, but during the procedure, the patient may be placed in the prone position or turned from side to side. After position changes, the team checks all lines and padding.

The surgeon’s preference dictates the choice of dressings; however, the choice will be a lightweight dressing. If the incisions are closed externally with skin glue, no dressing is needed.

Managing the patient’s pain
Postop pain management can take many forms. Before a lower body lift, the surgeon may place an epidural catheter to provide pain relief for 24 to 48 hours after surgery. Or the surgeon may insert a catheter, so a pain pump can be used postop. Analgesics from pain pumps last 3 to 4 days after surgery.

A surgeon may also order oral, intramuscular, or intravenous analgesics during the hospital stay. After discharge, the patient continues taking an oral analgesic, as needed.

Providing nutrition and emptying drains
When alert after surgery, patients begin with clear liquids. Gradually, the patient returns to a regular diet.

During most contouring procedures, the surgeon places several wound drains. Postop, a nurse teaches the patient how to empty the drains and record the output at home. At each postop visit, the surgeon or nurse evaluates the output. When output reaches 40 to 50 ml over a 24-hour period, the surgeon removes the drain and advises the patient to wear a compression garment.

Return to regular activity
The patient walks with assistance the evening of surgery. The hospital stay lasts 1 or 2 nights to allow the patient to recover from general anesthesia and the healthcare team to manage the pain and monitor hydration.

After a lower body lift, the patient needs considerable help to logroll out of bed. Also, the patient must walk in a bent-over position for several days. Too much incisional stress can cause wound dehiscence. Brachioplasty patients must keep their arms at heart level until lowering them doesn’t produce edema.

Postop patients should gradually increase the activity level day by day, as tolerated. Usually, the return to regular activity takes 4 to 6 weeks.

Postop visits
Body contouring procedures require many postop office visits.

Patients need support and encouragement, especially if complications develop. Preop discussion and teaching should help the patient know what to expect postop, but often patients are surprised by the reality of a long recovery.

Monitoring and treating complications
Patients with a higher body mass index before MWL have a higher risk of complications after body lift surgery. As with any surgery, complications such as infection and hematoma may develop. Most hematomas will resolve without treatment, though a large hema­toma requires surgery.

Complications specific to body contouring include seroma formation, skin necrosis, and wound dehiscence. A rare life-threatening complication, pulmonary embolus from deep vein thrombosis, may also develop.

Seroma, a collection of fluid, may cause noticeable swelling and discomfort. Managing this complication is often a major part of postop care, especially for patients who’ve had a lower body lift. After the surgeon removes the drains, the patient requires close monitoring to detect fluid accumulation. Small seromas don’t need treatment, but large ones that keep growing may need to be aspirated. Sometimes, a surgeon may order an ultrasound to assess the seroma. Depending on the findings, the surgeon may insert a drain to allow continuous drainage.
The goal of contouring is to remove as much skin and tissue as the surgeon considers safe while achieving adequate tissue circulation and wound closure. If the blood supply to the surgical area isn’t sufficient, some skin loss will occur. Skin necrosis may resolve with topical wound care, but sometimes it requires debridement.

If the patient moves too much or puts too much tension on the incision, wound dehiscence may occur. Once positioned in the hospital bed, a patient, especially a lower body lift patient, should not be moved until he or she is awake enough to feel the degree of tension caused by movement.

Patients may have decreased sensation along the incision for several months, and full sensation may never return. Most body contouring procedures produce extensive scars: around the entire lower body, from elbow to axilla, and from knee to groin. Patients often need reassurance that the raised, red scars visible after surgery will flatten and turn white with time. If a scar stays wide or thick, the surgeon may consider a scar revision.

Growing trend
As the number of obese people has increased, so too has the phenomenon of massive weight loss—and the number of body contouring procedures. If one of your patients asks about these elective surgeries, be sure to explain that they can’t be taken lightly. They require careful screening and planning, expert surgery and nursing care, and a very long recovery.

Selected references
Aly AS, ed. Body Contouring after Massive Weight Loss. St Louis: Quality Medical Publishing; 2006.

Aly AS, Cram AE, Heddens CJ. Truncal body contouring surgery in the massive weight loss patient. Clin Plast Surg. 2004;31(4):611-624.

Heddens CJ. An update on brachioplasty. Plast Surg Nurs. 2006;26(2):68-72.

Heddens CJ. Body contouring after massive weight loss. Plast Surg Nurs. 2004:107-115.

Kenkel JM, ed. Body contouring surgery after massive weight loss. Plast Reconstr Surg. January 2006;117(suppl):1S-83S.

For a complete list of selected references, see March 2007 references.

Claudette J. Heddens, ARNP, CPSN, is a Plastic Surgical Nurse at Iowa City Plastic Surgery, Coralville, Iowa.