A model for tandem postbariatric plastic surgery

Plastic surgery on the once morbidly obese is a growing segment of most plastic surgery practices in the new millennium. As our colleagues and we take on more of these types of patients, we find ourselves questioning how much surgery can or should be done on this type of patient in one session.

Are we pushing the safety envelope? Are there benefits to performing multiple surgeries at one time? And are there benefits in having two surgeons simultaneously carrying out these long operations? Before these questions can be answered, it is prudent to review some essential background information.

Obesity exists in epidemic proportions in the United States. The American Medical Association has reported that almost 50 million Americans are obese, and the trend is continuing.1 The number of illnesses associated with obesity is also increasing.2 Obesity is now the number-one cause of death in the United States, and it is increasingly burdening the health care system.3 The cost of the social impact of obesity on the US population is incalculable.

As a result of this growing problem, the number of weight-loss clinics and bariatric-surgery practices to treat obese people has increased considerably. We as plastic surgeons are now being affected by the outcomes of these treatments. More and more patients who have had bariatric surgery or have been successful with nonsurgical weight-loss methods are showing up in plastic surgeons’ offices, requesting the removal of their problematic leftover stretched skin and soft tissue.

Qualifying the Patient

Before accepting these patients for postbariatric surgery, the surgeon must consider many things. Is the patient nutritionally fit? Can he or she pass a stress test to prove sufficient fitness? Is the patient emotionally stable enough to withstand the operations?

It is important that the weight loss has stabilized—this usually takes 12–18 months. Finally, the patient’s financial condition must be considered. These operations are enormously expensive, and they are not yet generally covered by insurance.

When we evaluate a postmorbidly obese patient for surgery, we must first consider what concerns the patient the most. Although the plastic surgeon may focus primarily on the excess abdominal skin, the patient may be most focused on his or her arms, chest, breasts, face, or thighs.

When we plan our surgical procedure, we must determine where the resultant incisional scars will be. Importantly, the patient must understand where these scars will end up.

Just as there are numerous ways to lift the face, there are many ways to lift the body. Liposuction may or may not be combined with lifting procedures; and skin and soft-tissue excision can be performed with vertical incisions, transverse incisions, or a combination of both. Z-plasties are often necessary and should be used whenever appropriate.

Of course, the most important underlying concern is safety. Some surgeons will perform only one operation at a time; others will combine operations, but will place time constraints and consider fluid requirements and blood loss as limiting factors on how much surgery can be done safely. Another consideration—leading to differences of opinion among our colleagues—is whether these operations should be done on an outpatient basis or in a hospital.

The Advantages of Two

As more of these patients have appeared in our practice, we have decided to set aside 1 day per week to perform such operations as a duo. Almost all of the time, we perform the procedures on an outpatient basis. We have the luxury of sending our patients to a nearby overnight care facility, where they can receive around-the-clock nursing care. We require the patients to stay overnight in this facility; any additional nights are determined by the patient’s needs and desires.

We perform the operations in tandem because operating time is significantly reduced and multiple procedures can be performed in one session more safely with two surgeons than with only one. This arrangement is, in turn, much more cost-efficient for the patient—cost is always a top priority for the patient when considering elective surgery.

In addition, tandem surgery is less physically taxing on the individual surgeons, which indirectly improves safety. We are able to operate together because we have our own American Association for Accreditation of Ambulatory Surgery Facilities Inc–accredited facility, and we work well together. Many of our colleagues may find it difficult to work alongside another surgeon for various reasons.

Deep Sedation

Another unique feature that we provide for our patients is that the majority of these surgeries are conducted while the patient is under very deep sedation. The anesthesia is completely intravenous, and the patient breathes unassisted the entire time. The group of anesthesiologists who staff our facility has devised this technique in part with the aid of brainwave monitoring.

 We have never had to transfuse any of these patients. We always use sequential compression boots. We believe that some anemia actually helps decrease the risk of thromboembolism.

As stated above, every one of these patients is monitored and cared for by a nurse throughout the night following surgery, and none of them have required hospitalization. We routinely use compression dressings with garments, and we often use drain tubes.

Fortunately, our complications have been limited to local wound issues such as seromas, partial dehiscence, and very localized skin and soft-tissue necrosis. We always help the patients manage their scars postoperatively by keeping the scars taped for an extended period (usually 1–2 months). Afterward, topical devices such as allium cepa or polymyxin B sulfate strips are used.

In conclusion, postbariatric plastic surgery has become a regular staple of our practice. We are most comfortable tackling these long and sometimes physically demanding surgical procedures as a duo, but we do not deny that these patients are a large time commitment for our practice and require considerable hard work.

There is also an increasing risk as we continue to perform these combined operations on patients who were previously considered to be suboptimal candidates for large procedures. In the end, we do this because we find that this type of surgery is extremely rewarding for our patients—and for us as plastic surgeons. PSP

Michael A. Epstein, MD, and Rodger Wade Pielet, MD, are the owners of and partners in Aesthetic Plastic Surgery Associates in Chicago and Northbrook, Ill. They are both certified by the American Board of Plastic Surgery. They have been practicing aesthetic and reconstructive surgery of the face and body for more than 24 years combined. They can be reached at (312) 440-3100 (Chicago), (847) 205-1680 (Northbrook), or via their Web site, www.apsassociates.com.

References

1. Mokdad AH, Ford ES, Bowman BA, et al. Occurrence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76–79.

2. O’Brien PE, Dixon JB. The extent of the problem of obesity. Am J. Surg. 2002;184(6B): 4S–8S.

3. Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg. 2002; 6: 855–861.

Plastic surgery on the once morbidly obese is a growing segment of most plastic surgery practices in the new millennium. As our colleagues and we take on more of these types of patients, we find ourselves questioning how much surgery can or should be done on this type of patient in one session.

Are we pushing the safety envelope? Are there benefits to performing multiple surgeries at one time? And are there benefits in having two surgeons simultaneously carrying out these long operations? Before these questions can be answered, it is prudent to review some essential background information.

Obesity exists in epidemic proportions in the United States. The American Medical Association has reported that almost 50 million Americans are obese, and the trend is continuing.1 The number of illnesses associated with obesity is also increasing.2 Obesity is now the number-one cause of death in the United States, and it is increasingly burdening the health care system.3 The cost of the social impact of obesity on the US population is incalculable.

As a result of this growing problem, the number of weight-loss clinics and bariatric-surgery practices to treat obese people has increased considerably. We as plastic surgeons are now being affected by the outcomes of these treatments. More and more patients who have had bariatric surgery or have been successful with nonsurgical weight-loss methods are showing up in plastic surgeons’ offices, requesting the removal of their problematic leftover stretched skin and soft tissue.

Qualifying the Patient

Before accepting these patients for postbariatric surgery, the surgeon must consider many things. Is the patient nutritionally fit? Can he or she pass a stress test to prove sufficient fitness? Is the patient emotionally stable enough to withstand the operations?

It is important that the weight loss has stabilized—this usually takes 12–18 months. Finally, the patient’s financial condition must be considered. These operations are enormously expensive, and they are not yet generally covered by insurance.

When we evaluate a postmorbidly obese patient for surgery, we must first consider what concerns the patient the most. Although the plastic surgeon may focus primarily on the excess abdominal skin, the patient may be most focused on his or her arms, chest, breasts, face, or thighs.

When we plan our surgical procedure, we must determine where the resultant incisional scars will be. Importantly, the patient must understand where these scars will end up.

Just as there are numerous ways to lift the face, there are many ways to lift the body. Liposuction may or may not be combined with lifting procedures; and skin and soft-tissue excision can be performed with vertical incisions, transverse incisions, or a combination of both. Z-plasties are often necessary and should be used whenever appropriate.

Of course, the most important underlying concern is safety. Some surgeons will perform only one operation at a time; others will combine operations, but will place time constraints and consider fluid requirements and blood loss as limiting factors on how much surgery can be done safely. Another consideration—leading to differences of opinion among our colleagues—is whether these operations should be done on an outpatient basis or in a hospital.

The Advantages of Two

As more of these patients have appeared in our practice, we have decided to set aside 1 day per week to perform such operations as a duo. Almost all of the time, we perform the procedures on an outpatient basis. We have the luxury of sending our patients to a nearby overnight care facility, where they can receive around-the-clock nursing care. We require the patients to stay overnight in this facility; any additional nights are determined by the patient’s needs and desires.

We perform the operations in tandem because operating time is significantly reduced and multiple procedures can be performed in one session more safely with two surgeons than with only one. This arrangement is, in turn, much more cost-efficient for the patient—cost is always a top priority for the patient when considering elective surgery.

In addition, tandem surgery is less physically taxing on the individual surgeons, which indirectly improves safety. We are able to operate together because we have our own American Association for Accreditation of Ambulatory Surgery Facilities Inc–accredited facility, and we work well together. Many of our colleagues may find it difficult to work alongside another surgeon for various reasons.

Deep Sedation

Another unique feature that we provide for our patients is that the majority of these surgeries are conducted while the patient is under very deep sedation. The anesthesia is completely intravenous, and the patient breathes unassisted the entire time. The group of anesthesiologists who staff our facility has devised this technique in part with the aid of brainwave monitoring.

 We have never had to transfuse any of these patients. We always use sequential compression boots. We believe that some anemia actually helps decrease the risk of thromboembolism.

As stated above, every one of these patients is monitored and cared for by a nurse throughout the night following surgery, and none of them have required hospitalization. We routinely use compression dressings with garments, and we often use drain tubes.

Fortunately, our complications have been limited to local wound issues such as seromas, partial dehiscence, and very localized skin and soft-tissue necrosis. We always help the patients manage their scars postoperatively by keeping the scars taped for an extended period (usually 1–2 months). Afterward, topical devices such as allium cepa or polymyxin B sulfate strips are used.

In conclusion, postbariatric plastic surgery has become a regular staple of our practice. We are most comfortable tackling these long and sometimes physically demanding surgical procedures as a duo, but we do not deny that these patients are a large time commitment for our practice and require considerable hard work.

There is also an increasing risk as we continue to perform these combined operations on patients who were previously considered to be suboptimal candidates for large procedures. In the end, we do this because we find that this type of surgery is extremely rewarding for our patients—and for us as plastic surgeons. PSP

Michael A. Epstein, MD, and Rodger Wade Pielet, MD, are the owners of and partners in Aesthetic Plastic Surgery Associates in Chicago and Northbrook, Ill. They are both certified by the American Board of Plastic Surgery. They have been practicing aesthetic and reconstructive surgery of the face and body for more than 24 years combined. They can be reached at (312) 440-3100 (Chicago), (847) 205-1680 (Northbrook), or via their Web site, www.apsassociates.com.

References

1. Mokdad AH, Ford ES, Bowman BA, et al. Occurrence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76–79.

2. O’Brien PE, Dixon JB. The extent of the problem of obesity. Am J. Surg. 2002;184(6B): 4S–8S.

3. Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg. 2002; 6: 855–861.

A Tandem Surgery Chronology

Here is an example of how we perform postbariatric surgery in tandem. The patient was a middle-aged woman who had lost almost 100 pounds and was left with redundant sagging skin of the thighs, abdomen, breasts, brow, and face. Pielet saw her originally in consultation; therefore, he was deemed the lead surgeon for this operation.

Preoperative photographs were taken during a previous office visit approximately 2 weeks before surgery. During that visit, the patient signed consent forms and received postoperative prescriptions. Pielet and one of our patient-care coordinators also personally re­viewed her perioperative instruction sheets. During the 2weeks between the preoperative visit and the surgery date, Epstein reviewed the chart and photographs. We also discussed the operative plan.

The patient arrived between 7:30 am and 8 am on the morning of surgery. After she filled out some initial paperwork from the anesthesiologist, she was prepared for surgery by the recovery-room nurse. An intravenous flow was started, and initial vital signs were taken.

We met with the patient and made preoperative marks on her skin. The patient was then escorted into the operating room (OR) and was connected to monitors after one of the OR nurses performed a standing circumferential povidone–iodine prep.

The Thighs First . . .

We placed the patient on a sterile OR sheet and covered her with a second sterile sheet. The operation began at approximately 8:30 am. In this particular case, we started on the thighs. Tumescent fluid was introduced in and around the medial aspects of both thighs. After the epinephrine effect had taken place, incisions were created and minimal liposuction was performed.

Soft-tissue dissectors were used to undermine large skin flaps that extended down to knee level to maximize the lift and to remove as much skin as possible. We performed a medial thigh lift through a “hockey-stick” type of incision that extended vertically down the medial aspect of the thigh and horizontally to the buttock crease.

After the skin was removed and hemostasis was obtained, the skin flaps were inset with a number 0 nylon suture in the superficial fascial system, followed by a combination of numbers 20 and 30 absorbable poly­glactin sutures and a running number 50 plain catgut. The thighs were operated on simultaneously. The time was now almost 10 am.

We then turned our attention to the abdomen, where the abdominoplasty was completed in a high lateral fashion. Because the patient had a high midline vertical incision from her gastric bypass surgery, Z-plasties were created to lengthen the scar and to tighten the abdominal wall. A double-layer closure of the patient’s die stasis recti was performed with number 0 suture. Because we were able to sew simultaneously and essentially no additional liposuction was necessary in this case, the abdominoplasty took only a little more than 1 hour to perform.

It was now shortly after 11 am, and the patient underwent her breast lift in the standard way. Pielet had performed the markings and the skin excision. Each of us then closed a breast. By 12:15 pm, the patient was in her compression garment and sports compression bra.

. . . and the Face Last

We then turned our attention to her face. The bed was turned away from the anesthesiologist, and the head and neck were prepped and draped for her brow lift and facelift.

After we infiltrated the neck, face, and brow with a diluted local anesthetic and epinephrine solution, we performed a facelift with subcutaneous mus­cle–aponeurotic system (SMAS) and platysma elevation. Pielet performed the dissection on both sides while Epstein assisted. After skin excision and placement of the key sutures into the skin were completed, the peri-auricular incisions were closed simultaneously.

The brow lift was completed endoscopically, and by 2: 30 pm the head and neck dressing was applied. The patient was in the re­covery room by 2: 45 pm, and she stayed there till about 4 pm, when a nurse from the overnight-care facility arrived to transport the patient. By 5 pm, the patient was in her bed at the overnight-care facility, where she would receive continuous nursing attention. This facility is located 5minutes from the office and 5minutes from Epstein’s home.

Pielet saw the patient the next morning and removed the initial facial dressing. This patient desired to stay several nights, but this was not mandatory. This patient went on to do very well with essentially no complications.

—MAE and RWP