Understanding the characteristics of massive-weight-loss patients is as important as knowing how to operate on them

Surgery following massive-weight-loss (MWL), or bariatric, surgery is a unique field within plastic surgery in certain ways. It has aspects of both reconstructive and aesthetic surgery. As a plastic surgeon whose practice has many MWL patients, I have come to realize that these patients have unique characteristics:

• They all have a history of clinically severe obesity (the new term for massive obesity);

• they have undergone bariatric surgery with varying results, typically within the previous 1 to 4 years;

• they are strongly determined to get rid of their loose skin; and

• they are mostly women.

Aesthetic surgery on these patients has been on the rise as gastric-bypass procedures have gained popularity in the last 10 years. Bariatric surgery and subsequent aesthetic surgery for the MWL patient are challenging, and much has been written about these procedures. But the literature on understanding and dealing with the MWL patient is sparse.

For an aesthetic surgeon, identifying candidates for plastic surgery and knowing how to take care of the average patient can be challenging. It has been said that aesthetic surgery is psychiatry with a knife. MWL patients present a new challenge. These patients do not fit into a specific “mold,” but they have some common behaviors and medical issues.

For some, the decision to undergo bariatric surgery is part of a “new me” plan. They undergo a bariatric procedure, lose the weight, and find themselves ready to eat right, exercise, and in general alter the unhealthy lifestyles that had brought them to clinically severe obesity.

Changes occur in the process of weight loss with respect to family dynamics, romantic relationships, social interactions, work habits, self-esteem, and other life issues that may be unique to each individual patient. The more that plastic surgeons are tuned in to those changes, the better we are able to serve these patients. Ideally, plastic surgery on MWL patients provides enormously positive results for their self-image, self-esteem, attitude, and—ultimately—their health.

Preparing for Surgery

The secret of the care of the patient is in caring for the patient.

—Sir Francis Peabody

A user-friendly office. The first step in making MWL patients feel comfortable is to make them feel welcome and understood. It starts in the reception area. The chairs or sofas must be comfortable and able to accommodate large individuals. A warm reception from the office staff goes a long way toward making an already nervous prospective patient feel welcome.

The examination rooms should be equipped with exam tables and chairs for larger patients. Special large-sized gowns should be available, if needed. The office staff should understand the terms necessary to communicate effectively with MWL patients, such as “roux-en-Y,” “lap band,” and “dumping syndrome.”

The office manager or scheduler should explain the finances very clearly to patients, especially when the surgery is to be paid for out of pocket. The fees discussed should include those for the surgeon, hospital, and anesthesiologist. Pa­tients should also be made aware of fees associated with complications and touch-up procedures. This full disclosure is the honest and right thing to do, and it will give the patient a high comfort level from the beginning.

Whether your practice accepts insurance or not, your staff should have at least a minimal working knowledge of how to file insurance paperwork. They should also be able to write letters for the time patients need to be away from their jobs, help the patient in the event of a hospital admission, and explain to the patient how to obtain financing. A good relationship between the patient and the staff goes a long way toward ensuring a positive surgical experience.

The consultation. If you are genuinely interested in operating on MWL patients, it is important for you to thoroughly understand what they have been through and to know who their bariatric surgeons are, what techniques were used to perform their surgeries, and what their support systems offer.

Every plastic surgeon has a consultation routine. In my office, my nurse usually meets with a patient first. I then meet with the patient, listen to any concerns she may have after she has received information from the nurse, answer her questions, and allay her fears.

I make sure that enough time has been allowed, from a medical standpoint, for the patient’s weight to stabilize before operating. Depending on the bariatric procedure performed and the patient’s motivation and body habitus, that interval could range from 1 to 3years.

I ensure that the patient is in optimum condition from a nutrition and health standpoint before I perform the surgery. During the examination, I offer to draw the surgical plan on her body with an erasable marker and show the approximate locations where scars will appear.

I also make it a point to pinch the skin to be excised. This exercise has proven to be very important to make the patient aware of the location and potential quality of the scars. The patient can go home and share the markings with her significant other—or erase them—but this procedure definitely brings her expectations into focus.

After examining the patient, I share with her realistic, unretouched photos of patients who have a body habitus similar to hers and have had similar procedures. Because MWL patients have prolonged recoveries compared with typical plastic surgery patients and have a higher risk of complications, I very clearly discuss with her potential complications and realistic recovery times, as well as appropriate nutrition and exercise and a timeline for resuming sexual activity after surgery. I then allow ample time for questions.

If the patient wants to have multiple procedures, she and I develop a realistic, safe, and financially feasible plan to achieve a staged “extreme makeover.” At the end of the visit, my staff provides the names of patients who have had similar procedures and who are willing to talk to potential patients by phone.

If the patient wants to proceed with the surgery, she schedules a second consultation. In the interim, she obtains medical clearance for the requested surgery from her physician.

If, during the course of the consultation, e-mail correspondence, or communication with my staff I feel that the patient is not a good candidate for surgery, I do not hesitate to refuse to operate or cancel the surgery. As Ivo Pitanguy, MD, arguably the father of modern body-contouring surgery, once told me, “You make your money by the people you operate on, and your reputation by the people you turn away.”

Managing expectations. A patient who undergoes a bariatric procedure has dramatic changes in body weight and shape in a relatively short time. She can be on a psychological roller coaster. One patient confessed to me that despite losing about 180pounds and shrinking to a size 2, she would still go to the plus-size aisle subconsciously when she went shopping for clothing.

Having a gastric bypass is a commendable undertaking that takes a lot of courage and commitment after considerable thought. When patients lose all that weight, encouragement and compliments are in order. Some, however, develop a sense of entitlement that can be counterproductive. Losing the weight does not guarantee a patient the nice, sexy body that she had imagined when she closed her eyes and pictured herself 200 pounds thinner.

A patient who had lost more than 100pounds came to me for a lower-body lift. She wanted to look like Angelina Jolie. I explained to her that the surgery would greatly im­prove her body contour, but she would not look like Ange­lina Jolie even in the best-case scenario. After she repeatedly insisted that she expected to look like the famous actress—and I realized that she wasn’t kidding—I declined to operate on the basis of her unrealistic expectations.

There is a fine line between being positive when counseling a patient about what to expect from the surgery, and being manipulated by a patient to promise unrealistic results. A plastic surgeon must be empathetic with the MWL patient, but also must be realistic, even if the truth may hurt the patient’s feelings. It is better to turn someone away than to have a patient with perfect results who is unhappy because her expectations were not met.

After the Surgery

The good physician treats the disease; the great physician treats the patient who has the disease.

—Sir William Osler

Romantic relationships. A patient had just undergone a lower-body lift and medial thigh lifts in which about 11 pounds of skin had been removed. I was doing the initial dressing changes in the hospital the morning after the surgery. The patient’s husband was at her bedside.

When all the dressings were removed, the patient was ecstatic. But the husband’s reaction was very different from what I expected. He had a look of resentment mixed with jealousy.

He had been an obese man married to an obese woman. Now, she had lost more than 100pounds as a result of her gastric-bypass surgery, and, after body and thigh lifts, she had a physique that would soon be suitable for a bikini. He didn’t have to say a word. His look said it all.

In another situation, a patient told me that, when she was obese, her husband would never check up on her when she went out at night with her girlfriends. After having a gastric bypass—losing 90 pounds in the process—and an abdominoplasty, she noticed that he would constantly call her on her cell phone at night to make sure that she was “all right.”

As a plastic surgeon, it is important for you to ask the patient what procedure he or she is interested in, explain what to expect, and have the spouse present—if the patient wishes—so that there are no surprises and no ill feelings afterward. Both partners should have a realistic understanding of what the surgery will accomplish.

Self-esteem. A woman on whom I had performed an arm lift confided in me about a matter that had bothered her. She was highly accomplished in her field as a computer programmer and proud of her achievements. She had been clinically severely obese, had undergone gastric-bypass surgery, and lost 180pounds. However, she was angry with her mother because, despite her achievements as a career woman, her mother had not been impressed. She felt that the only time her mother was proud of her was when she had lost the weight.

MWL patients are often professionals; they are generally intelligent and sometimes incredibly well-accomplished. To ignore all other facets of their personas, and focus only on their body shapes, is doing them a terrible injustice.

Social needs. When a woman is convinced that she wants to lose 100pounds, and undergoes a potentially dangerous surgery to achieve that, her perceptions of what is important in life and what is acceptable to her can change. Patients who lose a significant amount of weight can sometimes undergo an identity crisis. They don’t enjoy hanging out with their old friends who may still be overweight or obese, because eating may be at the center of their social activities—a situation that an MWL patient is trying to avoid. MWL patients can also be put into the “now that you are thin, do you think you are better than we are?” situation.

There is a positive aspect to that experience. Bariatric surgeons and their staffs have made superb efforts to create an excellent support system for potential and actual bariatric patients. “Staple clubs,” as they are affectionately called where I practice, are a wonderful creation. They are support groups that provide medical help, nutrition and fitness advice, guest speakers, and other helpful services.

The camaraderie that patients have with one another is probably the most important benefit of the staple clubs. One very supportive activity is the clothing exchange: As a patient drops a size every few weeks, she does not have to constantly buy new clothes. This, and sharing experiences on Web sites dedicated to bariatric patients, gives patients a sense of identity and belonging that they need at a time when life can be frightening even though positive changes are occurring.

A plastic surgeon must be sensitive to these recent or ongoing social changes in the lives of MWL patients, and try to use them for the patient’s full benefit when planning for the surgery and the recovery period.

Complications. Unfortunately, MWL patients have a significantly higher com­pli­cation rate than other aesthetic-surgery patients. Rea­sons for complications could in­clude poor nutrition, malabsorption, anemia, attenuated fascia, poor blood supply, loss of skin elasticity, and illnesses or medical conditions associated with obesity—such as cardiac illness and diabetes—that have not quite resolved despite the weight loss.

The most common complication from body-contouring surgery after massive weight loss is skin necrosis, which usually occurs in a small area and creates a wound that requires dressing changes. One of my patients who underwent a body-contouring procedure developed a wound, and we worked together to heal it. I taught her and her husband how to change the dressings, saw them frequently, and monitored her until the wound healed. I felt bad that a very nice woman like her had to deal with this complication.

Much to my surprise, she told me that this wound was the best thing that had ever happened to her. I was perplexed. She explained, “I was planning on having this surgery and divorcing my husband afterward because he had been cheating on me for years. The way he cared for me after the surgery, and the attention he gave me, made us fall in love all over again. Now, we are inseparable, thanks to my wound and his great nursing skills!” Needless to say, I was in awe.

The lesson to be learned from this is that sometimes there is opportunity in adversity. MWL patients are vulnerable. Some of them have had bad experiences with the medical establishment from their days before bariatric surgery. They may require more time and energy than the average patient to get through managing a complication, but the satisfaction generated, and the gratitude of the patients, make it immensely worthwhile.

Follow-up. MWL patients fall into two categories in terms of the reasons why they undergo bariatric procedures. The first group consists of those who could not tolerate being obese any longer and decided to turn their life around by self-motivation and a lot of determination. The second consists of patients who were pressured into having a gastric bypass—by husbands, who would verbally abuse them because of their weight; by physicians, who told them they could die at age 40 from high blood pressure or diabetes; or by co-workers, who, overtly or subtly, discriminated against them because they were obese.

Some people gain the weight back gradually after the bariatric procedure. In my experience, the people more likely to regain the weight are the ones in the second group—those who were pressured into having the bariatric surgery in the first place.

One patient underwent multiple body-contouring procedures over a 2-year period. She was one of my model patients: She was pleasant, followed medical instructions, healed without problems, had great results, and made herself available to talk to people who sought similar procedures.

When she did not show up for her follow-up appointment 1 year after surgery, I suspected that she had been gaining weight and was too embarrassed to see me. She had, in fact, regained about half the amount she had initially lost, and had also lost the self-esteem boost that she had received from the aesthetic procedures. My staff offered to help her by arranging for a meeting with me for counseling, a nutritionist, and a fitness instructor to help her lose some of the gained weight. The results are pending.

Diligent follow-up with MWL patients is critical. These patients were under the care of the bariatric surgeon and his or her support staff before undergoing plastic surgery. By the time they have had their plastic surgery procedure, they have lost that support system, so it is the plastic surgeon’s responsibility to motivate the pa­tient to avoid gaining weight, to exercise, and to lead a healthy lifestyle. Being compassionate with our patients does not mean we cannot be tough with them and express our disapproval when they indulge in self-destructive behavior.

Lessons Learned

When you do something long enough in any field, you learn a thing or two about it. Here is a summary of the lessons I have learned:

• MWL patients are a unique group, and they should be treated as such.

• Plastic surgery is often perceived by the MWL patient as one segment of a long and arduous journey.

• Having a practice that is user-friendly to MWL patients goes a long way toward ensuring a successful physician–patient relationship.

• It is crucial to set realistic expectations during the initial consultation.

• It is the plastic surgeon’s responsibility to educate the MWL patient as thoroughly as possible about what lies ahead.

• If a patient wants an “extreme make­over,” it is important to make a realistic plan initially so that there will be no disappointments later.

• Turning a prospective patient away for the appropriate reasons may be the biggest favor you can do for that person.

• It is important to understand the patient’s family dynamics and support system to optimize the medical and social outcomes of surgery.

• MWL patients have accomplishments and achievements that should be celebrated along with the body transformations from surgery.

• Support systems for MWL patients are available in the community, and they can serve both the patient’s and surgeon’s interests if used appropriately.

• Bariatric patients have a higher risk of complications, but managing them successfully only enhances the surgical experience and creates a strong bond between the surgeon and the patient.

• Being compassionate and encouraging to our patients does not mean we cannot be tough with them when it is for their own good.

Frequently, long after the surgery is over, an MWL patient has turned her life around, and she comes back to our office healed in every sense of the word. She enters with a glimmer in her eyes to show the staff her new engagement ring—or her newborn baby after she was told she could not have children. At those mo­ments, my staff is overcome with a sense of magical joy, and we know that all she has gone through has been worth it! PSP

George John Bitar, MD, is a board-certified plastic surgeon in private practice in northern Virginia. He is on staff at INOVA Fairfax Hospital in Falls Church and Prince William Hospital in Manassas. He can be reached at (703) 206-0506 or via his Web site, www.drbitar.com.

Acknowledgment

Special thanks to Osvaldo Anez, MD, an exceptionally skilled and compassionate surgeon who opened the doors for me in the field of MWL surgery.