The first time that Los Angeles 
plastic surgeon Susan Downey, MD, performed a panniculectomy on a postbariatric surgery patient in the early 2000s, she jumped in immediately after a general surgeon repaired a large superficial hernia.

A lot has changed since then. As weight-loss surgeries became less invasive and more common, postbariatric body contouring experienced a parallel growth and has now become something of a cottage industry and a profitable niche for plastic surgeons.

Once nestled amid other plastic surgery statistics, postbariatric body contouring surgery is now a category of its own among associations that tally surgical trends. In 2013, 41,998 body contouring procedures were performed on massive weight-loss patients, according to the American Society of Plastic Surgeons (ASPS). Part of this innovation was fueled by collaboration among surgeons as well as partnerships with industry.

“There was no textbook or guidelines to follow in the beginning,” Downey says. “We had to figure it all out on our own. We would talk to each other and learn from each other,” says Downey, also a clinical associate professor of plastic surgery at the University of Southern California’s Keck School of Medicine. She is considered one of the pioneers in this field, and her work has put these procedures on the map. Downey co-authored five chapters of various textbooks on plastic surgery after weight loss and helped run one of the ASPS’ longest-running teaching courses on postbariatric surgery.

PostBariatric Surgery Evolution

At first, most massive weight-loss patients were concerned about the hanging pannus, but soon they began asking about other body parts. “The belly was relatively easy and we got good at it quickly, so then we started to add on arms, too,” she says.

Early on, demand fostered innovation, she says. “University of Pittsburgh plastic surgeon J. Peter Rubin, MD, has a great technique for breast augmentation in postbariatric patients. He mobilizes some of the extra lateral breast folds and uses it to autoaugment the breast,” she states. A similar method is also used to recontour or augment the buttocks, which tend to sag among massive weight-loss patients, she says.

Many of the advances developed were based on the techniques first published by Ted Lockwood, MD. Lockwood, a clinical assistant professor of plastic surgery at the University of Kansas Medical School, Kansas City, is considered the forefather of the lower body lift. He passed away in 2005. “Dr Lockwood got us to think in units and about how addressing one area of the body impacts another area,” Downey says.

Pretty soon, industry got involved, too. Downey recalls a time when a medical director from Ethicon observed her in the OR. “He noted that we spent too much time suturing,” she says. As a result, the company started to develop products to make closing easier and faster. Advances such as Ethicon’s Prineo Absorbable Sutures system and barbed sutures were the result of these collaborations.

Up In Arms

Body contouring focused a lot on the trunk at first, but now breasts, face, and extremities are growing in popularity, adds James J. Chao, MD, a plastic surgeon in San Diego and professor of surgery in the Division of Plastic Surgery at the University of California, San Diego. The top five postbariatric surgeries in 2013 were lower body lift, thigh lift, arm lift, breast lifts, and tummy tucks with or without panniculectomy, ASPS reports.

“The largest uptick we are seeing is in extremity contouring,” Chao says. He predicts that postbariatric surgery facelifts will be the next procedure to experience a boom. “The massive weight-loss patient can have a large, heavy neck,” he says. “Technology, including Novus’ TIGR bioresorbable mesh, may have a role because we can’t stretch the skin far enough without distorting the face in patients with heavy necks,” he says. “If we stretch it too much, it will become distorted, so what we need is support of soft tissue.”

The surgeries and the order in which they are performed were not the only paradigm shift in postbariatric body contouring. Patient expectations also changed. The biliopancreatic diversion with duodenal switch surgery’s popularity as a weight-loss method dwindled in favor of gastric bypass and the minimally invasive gastric banding and gastric sleeve procedures.

“We have moved from open gastric bypass and other surgeries with big cuts to much less invasive gastric banding and gastric sleeve surgeries,” Chao says. Today, the field is rapidly moving toward incisionless surgery that is done through natural orifices, he tells Plastic Surgery Practice. “You can go through the mouth for a gastric sleeve and have no holes,” he says.

This ups the ante for plastic surgeons, as previously these patients presented with a wide-open scar and were more accepting of any scars associated with cosmetic surgery. “Now they have a few holes at best, so anything we do will create a bigger scar than what is already there,” he says, noting the irony. “If a patients had an operation and dropped 80 pounds with no scar, and now they are coming to my office and I tell them they may have a mile-and-a-half scar, I won’t sell too many cakes,” he says.

“We need to learn to hide the scars better for these incisions,” he says. This may involve the use of Neodyne tape or other energy-based technologies,” Chao predicts.

Still, Downey adds, “these patients are very accepting of scars, much more so than other cosmetic patients,” she says. “They acknowledge the scarring but still feel so much better about themselves than they did before because we are really fixing something,” she says. “Patients accept even adding scars such as a long lateral scar down the entire extent of the thorax when there is a marked improvement of the contour of their abdomen.”

First, Do No Harm

Much of what has been learned about these procedures focuses on their safety—especially given the heightened risk profile of massive weight-loss patients.

“There is a very strict criteria for these very expensive procedures, and cost may be a deterrent for some patients.” —Susan Downey, MD

For example, a recent study found that patients who lose more than 100 pounds either through diet and exercise or bariatric surgery are at higher risk for complications following body contouring procedures. Specifically, major weight loss was a significant risk factor for wound complications in body contouring surgery, the new study showed. One reason why postbariatric patients have more complications is nutritional deficits.

Following bariatric procedures, many patients consume less than 1,000 calories daily, which leads to lower protein levels and nutritional shortfalls. Their bodies adapt to their new nutritional state, which then changes when the body becomes stressed by surgery. The findings were published in the Aesthetic Surgery Journal.

“Some postbariatric patients are walking around anemic and not taking their vitamins or eating as they should be,” Downey says. ”These patients can develop large and potentially life-threatening hematomas,” she says. “If the patient has an increase in blood pressure and their heart rate is up, it’s a hematoma until proven otherwise.”

Nutritional shortfalls are more common among patients who had malabsorptive weight-loss surgery, but they can also occur when other bariatric patients are not complying with their dietary recommendations. “The stress of the surgery can also unearth some deficiencies even if the patients are optimized before the procedure,” she says. “We give our patients a ‘banana bag’ of vitamins, including thiamine for extra nutritional support,” she says. “We also check the patient’s labs before the procedure is even scheduled to make sure if the numbers are where they should be.”

That said, these patients are much healthier and better surgical candidates than they were before the initial weight-loss procedure. “They often decrease their American Society of Anesthesiologists score from a 3 to a 2 following bariatric surgery,” she says.

“Just because this surgery is elective doesn’t mean it’s not fraught with dangers,” Chao adds. Safety will likely be much improved by real-time data gleaned from initiatives such as the Surgical Momentum’s clinical quality improvement program. “This open-sourced data set can help us benchmark how long the surgery took as well as complication rates in real time, and compare that to a national average,” he says.

“These are all the measures that over time will give you the box scores of a baseball game as opposed to a final score,” he says. Importantly, the data gets sanitized, so it is somewhat anonymous.

Come What May

While such data will clearly help plastic surgeons forge ahead and improve upon their techniques, insurance companies along with health care changes have been throwing up some roadblocks for patients interested in postbariatric procedures and the surgeons who perform them.

“There is a very strict criteria for these very expensive procedures, and cost may be a deterrent for some patients,” Downey says.

This is likely why the procedural numbers are down slightly from 2012. Research on the benefits associated with these surgeries may help encourage better coverage. The latest study suggests that patients who undergo cosmetic procedures after massive weight loss will maintain a lower body mass index than their counterparts who don’t. This research was presented at the 2014 ASPS annual meeting in Chicago. In around 15 years of follow up, the mean end point BMI of patients who underwent body contouring was 24.6 versus 31 in those who did not.

“These surgeries truly improve a patient’s quality of life,” Downey says. “In many cases, they straddle the line between cosmetic and reconstructive, and truly help give a person back their life.”

Denise Mann is the editor of Plastic Surgery Practice. She can be reached at PSPeditor@allied360.com.