Explore Plastic Surgery

Bariatric, or weight loss surgery, continues to be on the rise with a large portion of the U.S. population officially defined as obese. Gastric bypass surgery, also known as Roux-en-Y, is the most popular surgical method in the U.S. to obtain massive weight loss. While many gastric bypass patients are desirous of plastic surgery to improve their residual body deformities left after the weight loss, less than half actually ever do priamrily due to economic considerations. One very interesting question is that in those patients who do udnergo body contouring surgery, after all the effort and expense, is their weight loss maintained?
Dr. Michele Shermak and others from Baltimore at Johns Hopkins attempted to answer this question in a recent article in the June issue of Plastic and Reconstructive Surgery. Over four years, they collected data on 70 patients who lost an average of around 140 lbs and had body contouring surgery after with an average removal of skin and fat of near 13 lbs. Their data showed that gastric bypass patients susbsequently gained around 2 lbs whereas those patients who lost the weight without gastric bypass surgery (diet) gained close to 22 lbs. It should be pointed out that the patient numbers for the diet group were quite low (6) compared to the gastric bypass group. (64) Statistically, however, the difference was still significant.
This paper concludes that gastric bypass surgery patients maintain their weight loss better than those patients who lost it by diet alone. I don’t think that this finding is that surprising. The ‘why’ of it undoubtably has to do with ther permanent alteration of nutrient absorption by the bypass. Diet weight loss patients must maintain their weight loss by the mental restriction of food intake, they simply can relape back faster as their ability to absorb nutrients is unaltered. In either case, bariatric plastic surgery produces successful results. Gastric bypass patients are just better at maintaining their investment due to their altered gastrointestinal anatomy.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Of the many body deformities that result from excess skin after massive weight loss in the bariatric surgery patient, the most difficult in my experience is that of the breast. Loss of breast volume, a low nipple position, and sagging skin from a ‘deflated balloon’ creates a breast problem that offers a lot of challenges. Lifting and reshaping a bariatric breast is a four-dimensional problem consisting of tightening and lifting the skin sleeve, elevating the nipple into a more central position on the breast mound, adding loss breast volume, and trying to minimize the amount of scars necessary to do accomplish all these tasks.
The real challenge in making a better breast in the bariatric surgery patient is that lifting and reshaping the breast and adding volume through an implant (which is almost always necessary) makes it very difficult to predict an exact final result. Then when you factor in the important task of keeping the nipple alive through these manuevers (removing excess skin and putting in an implant can inadvertently knock off the blood supply to the nipple), raises the risk of further complications.
Based on these concerns, I advise patients that I will do my best to get a good result in one operation, but my experience has shown that it usually takes two separate procedures to get the best outcome. In other words, the revision rate in these types of breasts is quite high. Whether more skin needs to be tightened, the implants need to be repositioned or adjusted in volume, or the nipple needs to be lifted even higher, it is very difficult to get two, fairly symmetric breasts that match. Inevitably, some aspect of one breast or the other is ‘off”. Therefore, I advise my patients to think of their breast procedure as a two-staged operation with the hope that we do good enough that some patients will get by needing only one procedure. None of this has factored in the issue of scars and how they look which poses another risk. Fortunately, most breast scars turn out fairly well although it takes a considerable amount of time until they blend in well.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

In the male bariatric surgery patient who has undergone massive weight loss, the resultant chest wall (breast) deformity is often of major concern. The appearance of the male chest, like the female breast, is of understandable significance. This male chest deformity is often called gynecomastia but this is inaccurate and actually signifies a different pathology. Gynecomastia is the enlargement of native breast tissue producing an enlarged nipple-areolar complex to a decent-sized breast. Chest deformity after massive weight loss is a deflation (loss of breast tissue) with resultant skin excess, sag, and a low-hanging nipple. As such, they are quite different from each other in many cases.

In some male bariatric patients, simple liposuction with or without a nipple lift, may be all that is needed. But in many cases, this is simply inadequate. The problem is what to do with the sagging skin and how to get the nipple positioned up higher on the chest……without creating a lot of scarring. (which may be worse than the original problem) In short, there are no easy answers to these issues.

Possibilities for correction include staged, repeat nipple lifts (each time inching it up higher), pectoral implants to add some volume (but you can’t have too much skin or this makes it look worse), or cut-outs of skin along the bottom part of the chest out to the side with the resultant scarring. Either way, getting the nipple up higher and removing excess skin often fights against each other.

Male chest ptosis (sagging) after massive weight loss is somewhat similar to that of the aging male’s chest problem. (but usually with less extra skin) Both are ‘deflation’ issues with low nipple positions. Most of the time a compromise has to be reached. Which is more important….tightening the skin or lifting the nipple? I usually encourage the male patient to avoid any significant scarring on their chest. While cut-outs of skin can very effectively tighten and lift the sagging chest, the resultant scars will usually make you feel no better about your chest problem. If your goal is only to look better in a shirt, then this might be an option. However, I caution the male patient about scarring. Even if they think it won’t matter, there is no magic eraser to take it away later.

As you can see, the male chest in massive weight loss poses a dilemma for many patients to which there is no easy solution in the extreme cases. A good in-depth discussion with your plastic surgeon is really needed here. The consequences of plastic surgery must be balanced against the original chest wall deformity to be certain that enough improvement can be obtained to make the surgical experience worthwhile.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

For many massive weight loss patients (> 100 lbs), the thigh is often the last stage of body contouring that is done. It is always a good idea to see how much result you can get in the thighs after the abdominoplasty/panniculectomy/circumferential body is completed first. While these procedures won’t make a dramatic difference in the thighs, they do have some lifting effect in the upper portions of the inner and anterior thigh areas. I never do thigh lifts in conjunction with an abdominal/body lift procedure as that is an enormous of sweing with lengthy operative times. Plus I don’t like the thought of a narrow strip of skin between the abdominal and thigh incisions from a blood supply/survival standpoint.
Thigh lifts in the massive weight loss patient are very different from the typical thigh lift procedure. First and foremost, the amount skin in all dimensions is simply greater. Therefore, the typical cutout pattern with a resultant scar isolated to the groin crease is not going to be sufficient. A good amount of improvement can not be done this way despite the fact that the scar is fairly well hidden. Second, the excessive thigh skin exists in three-dimensions, meaning both horizontal and vertical skin cutouts must be done to make a true size reduction. This results in an extra scar running down the inside of the leg to at least the knee and sometimes past it. Third, as the scar burden has increased so the the ‘typical’ postoperative problems which can occur including wound separation at the T (junction of horizontal and vertical scars), fluid build-up after drain removal, and some degree of scar thickening.
Like many bariatric plastic surgery procedures, thigh lifts result in a lot of scar but they are tremendously effective. They are not painful to go through other than some discomfort from being tight in the groin area. Recovery from a thigh lift really relates to the need to limit the amount of walking that you do in the first few weeks after surgery so as not to put too much stress on the incision sites.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Of the many bariatric surgery patients that I have seen over the years who have lost 100 or more pounds, the concern over their saggy arms is often a top concern. I would have to say that the arm concern combined with the stomach or waistline are almost always the top two priorties of the massive weight loss patient. I should add one caveat, the arms are an issue exclusively for women. I have yet to see a male patient who has put forth this concern to me. That does not mean that men don’t develop flabby arms after bariatric surgery, it just doesn’t cause the same problems that it does for women.

Because of high arm concerns, most female bariatric surgery patients often undergo a combination of an arm lift (brachioplasty) and an abdominoplasty as the first stage of their body contouring. Full arm lifts, which all bariatric surgery patients require, always result in a long arm. The patient can choose whether this scar ends up on the inside of the arm or on the back of the arm. There are arguments for its placement in either location. It is a choice of whether you see the scar but others not so much so (inside of the arm) or whether others see it but you can’t. (back of the arm) Either way, I caution patients that, from my perspective, I have seen very few good-looking scars. Scar from arm lifts seem to do rather poorly in terms of their width, redness, and their tendency for hypertrophy. (raised scar) I think it is the very thin skin and the tension that it is under from the tight closure that makes them often appear fairly unsightly. While they can be raised revised later, from which they turn out much better, an arm scar that parallels the vertical axis of the arm is one of the poorer scar outcomes from body contouring in the bariatric surgery patient. Then there is the scar banding (contracture) issue that can occur as the scar crosses from the arm into the axilla. (armpit) It is always necessary to bring the skin excision pattern into the armpit and often down into the side chest wall. Like all scars that cross areas of movement, a tight band often develops. Sometimes I have incorporated a Z-plasty into the skin cutout and other times, I have just waited to see whether a bothersome scar contracture develops. For most patients, the degree of improvement in the shape of their arms seems to overshadow significant concerns about an axillary scar contracture.

One of the nicest things about an arm lift procedure is that it is associated with little to no postoperatve pain and recovery from it is fairly quick. Other than some mild swelling in the hands during the first few days after surgery, most problems with arm lifts are relatively minor including snall fluid collections (seromas), spotty areas of delayed incisional healing, and the scar issues previously mentioned. For these reasons, an arm lift is a perfect compansion to other more major body contouring procedures in the bariatric surgery patient such as tummy tuck, circumferential body lift, and breast lift/implants.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

With the tremendous increase in the number of bariatric surgeries performed in the past five years, to no surprise there has been a near equal increase in the number of post-bariatric body contouring procedures performed to deal with the resultant excessive hanging skin. These bariatric plastic surgery procedures include arm lifts, breast lifts, abdominoplasties, thigh lifts, buttock lifts, and the circumferential body lift.

The circumferential body lift, while an ‘old’ procedure per se, has been reborn in great numbers as a result of massive weight loss patients. The circumferential body lift, or a 360 degree tightening and lift, is really a combination of a frontal abdominoplasty and posterior hip and buttock lifts. In bariatric patients, many will have a frontal overhang of skin (with a sagging pubis) but with a buttock and thigh droop on the backside. The circumferential body lift works so well because it removes excessive overhanging abdominal skin (with a pubic lift) and lifts sagging buttocks, hips and thighs. In the properly selected patient, the resultant circumferential scar around the waistline is worth it. And, surprisingly, it is not a painful procedure to go through unlike what many would think.

If the patient has a midline vertical scar from an open gastric bypass procedure, then the body lift is combined with a ‘vertical wedge’ cut out along this midline scar. This helps produce some horizontal waistline tightening which, without it being done, would not happen as much. If the patient doesn’t have a vertical midline scar then I rarely do this as part of the body lift so as to not make more scar than the patient will already have.

One thing the body lift can not do is to increase the size of the buttocks. Most massive weight loss patients will develop a very flat buttock appearance. While there have been some variations of the body lift touted as taking the excess skin and fat from the back and using it as a ‘buttock implant’, this rarely produces enough bulk in the right place of the buttocks to make it worthwhile. And there are some risks in doing this as part of the body lift procedure. I tell my patients to think about buttock augmentation as a later procedure. It is likely that this concern will fall off the list for many patients over time.

The most significant complications that I have seen in body lift patients are fluid collections (seromas) and wound separations (in the front at the inverted T if a midline wedge is cut out and at the back just above the gluteal cleft). I tell every patient that the likelihood of these issues is very high and most patients will develop some variations of one or both of them. Fortunately, they are managed not by further surgery but by needle aspirations and dressing changes until they heal themselves. These issues always occur, not early, but between 2 to 4 weeks after surgery. If you reach a month after surgery without any of these common problems, then they are not likely to occur.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

According to the annual statistics of the American Society for Aesthetic Plastic Surgery, the number of body contouring procedures performed has dramatically increased over the past five years. Abdominoplasty, lower Body Lift, buttock lift experienced a 200% gain while thigh and upper arm lift experienced a 400% rise. This parallels and is due to the increased number of patients that have undergone bariatric weight loss surgery.” According to Allergan, manufacturer of the Lap-Band® bariatric procedure, 350,000 of these devices have been placed worldwide. Nearly 100,000 bariatric procedures, of either the LAP-Band or bypass variety, were performed last year in the Unisted States alone.
After these patients’ large weight loss, loose skin remains that can only be removed surgically. The abdomen, with the skin frequently hanging down like a drape hiding the belly button and pubic area, is a major problem as is excess skin of the arms, thighs, breasts, and faces. These patients seek out plastic surgeons to correct these problems. The American Society of Bariatric Plastic Surgeons(ASBPS)was founded to help meet the needs of these patients. It is composed of plastic surgeons that specialize in body contouring after weight loss.

Cheryl, who lost 125 pounds after her gastric bypass had an outward appearance left her disappointed and discouraged. She waited until her weight stabilized and then had face and body contouring. A Lower Body Lift (an Abdominoplasty and Buttock Lift) and Facial surgery were performed as a hospital inpatient. Then, several months later, she had a Breast and Upper Arm Lift and Liposuction as an outpatient. “For me, having the plastic surgery was like crossing the finish line with my weight loss journey,” said Cheryl.
As gastric bypass and LAP-BAND® procedures exponentially increase, so too will body contouring operations. Even though the number of post-bariatric patients seen by plastic surgeons has dramatically risen over the past five years, it is projected that these numbers will become overwhelmed in the coming years by these patients seeking cosmetic improvement.

Dr Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Dr. Barry Eppley of Indianapolis joins The American Society of Bariatric Plastic Surgeons

As the number of bariatric surgeries performed in the United States continues to increase, so has the number of patients that have been left with large amounts of loose skin after massive weight loss. The success of bariatric surgery has led to a completely new subspecialty of plastic surgery, Bariatric Plastic Surgery. While many of the face and body contouring procedures are not necessarily new, how and when they are performed in the bariatric patient with large amounts of skin are different from the non-bariatric patient. The extent of the lifting procedures, how different procedures are done together or staged, and before and after surgery management and considerations are different in this new generation of potential plastic surgery patients.

The recognition of the unique needs of the bariatric patient can be seen in plastic surgery by the numerous courses dedicated to the topic over the past five years, presentations at national meetings, and textbooks devoted to the topic. It is very appropriate, therefore, that the American Society of Plastic Surgeons has recognized this growing subspecialty and has sanctioned a special organization for it, The American Society of Bariatric Plastic Surgeons, http://asbps.org. This society provides a comprehensive resource and a central poinjt for both patients and plastic surgeons alike to research the topic and find qualified and experienced plastic surgeons in this field. I am happy to become a member as my patients, both present and in the future, will benefit.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

You Did It!

Losing a lot of weight is the beginning of a new life. When you still have folds of loose skin left over, however, your body may be smaller but not be any more pleasing than before your bariatric surgery. Because of the loose skin, you may still feel inadequate and embarrassed. Fortunately, a unique plastic surgery program is available to you. Through the FORM program, we can tighten sagging skin after weight loss and give you the body shape that you have worked so hard to achieve.

Looking Your Best

Plastic surgery is often the final step in the surgical weight loss process. The overstretched skin is damaged, has lost its elasticity, and cannot conform to the new shape of the underlying body. This can result in sagging neck, breast, arm, stomach, back, and thigh skin. This excess skin poses cosmetic, hygiene, and comfort issues. Nothing can restore the skin’s elasticity, the excess skin must be removed and each body area reshaped. For some patients, only one or two excess skin areas are of concern. For others, sagging skin is present from the neck to the knees.

Your New Body

Through the FORM program, a series of body contouring surgeries is done, each targeting a specific area of loose and sagging skin. These operations require a high degree of surgical skill and attention to detail as well as an aesthetic eye to ensure that you achieve a pleasing body contour. Procedures include:

Abdominoplasty (Tummy Tuck)
Body Lift (Tummy Tuck and Back Lift)
Brachioplasty (Arm Lift)
Breast Augmentation (Breast Implant)
Facelift (Neck and Jowl Lift)
Mastopexy (Breast Lift)
Thighplasty (Hip and Thigh Lift)

The key to successful post-bariatric body contouring is to select not only
the right operations but how to stage or sequence the body areas being contoured
to safely obtain a good result. The FORM body program helps guide you through these decisions, choosing those surgeries that are of most importance to you.

Your physical and mental health is of utmost importance, both must be in good shape to undergo intensive surgery that can last up to six hours or more under general anesthesia. While dramatic body changes are possible, you must be willing to accept scars in place of the loose skin.

Surgical Expertise

The FORM program was developed by me as a method of approaching the cosmetic problems of the bariatric patient who has undergone massive weight loss. Through an in-depth consultation and thoughtful treatment planning, a safe and realistic plastic surgical plan can be created for your body to meet your goals and be done with attention to the needs of your home and work life.

Insurance and Body Contouring

The increasing number of bariatric surgeries performed has created many patients seeking body contouring procedures. Just because insurance has covered your bariatric surgery is not a guarantee that they will cover any body contouring surgeries. If there are medical problems that the loose skin is causing, then the surgery may be covered. This can only be determined, however, through an insurance predetermination process. We routinuely handle this insurance step for you. As a general rule, loose abdominal or thigh skin may be eligible for coverage; neck, arm, and breast problems are usually not covered.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis