More Than Just Skin Deep

Obesity has become one of the most challenging health issues of our time. For most patients who lose more than 100 pounds over a relatively short period, bariatric surgery is just the first step in an arduous process toward renewed self-esteem.

Whereas a significant weight loss improves a patient’s health and lifestyle, the resultant skin redundancy and fascial laxity often require additional treatment. The areas affected may include the arms, breasts, abdomen, back, thighs, face, and neck. The next phase of this journey is often a series of surgeries to restore the body to a more aesthetically pleasing state.

In some ways, patients can actually look worse after a large weight loss. Therefore, it is important that you give them a realistic view of what body-contouring surgery can achieve.

Patients may be motivated to change their appearance, but they are not always aware of the severity of the surgery and the extent of the healing phase. It can be hard to prepare patients for the potential complications, but proper wound care and an enormously supportive approach serve to accelerate healing and improve surgical outcomes.

Individual Needs

“Massive-weight-loss patients have unique needs, and these special issues need to be considered in their management,” says Tracy Pfeifer, MD, a plastic surgeon who practices in New York City. “For plastic surgeons, support and education are the cornerstones of success in managing this new and evolving group of patients. Both before and after their surgeries, there is an ongoing need to focus on nutrition, physical activity, and behavior modification to avoid the traps that have sabotaged weight-loss maintenance efforts in the past.”

Patients may present to plastic surgeons at various stages. Either they are currently overweight and request a reduction of excess fat and skin, or they have had a substantial weight loss and desire correction of contour deformities. Factors that affect optimum management include age, baseline weight, overall health status, motivation, commitment, and the extent of the procedures performed.

Dennis J. Hurwitz, MD, clinical professor of surgery (plastic), University of Pittsburgh Medical Center, and author of Total Body Lift (MDPublish, 2006), explains, “Patients requiring surgical skin excision after massive weight loss for functional and/or aesthetic reasons require individualized approaches with intensive follow-up. The postoperative management begins with thorough preoperative preparation that continues through the early healing period.

“Weight-loss patients, particularly if there has been gastric and intestinal bypass, will have nutritional deficiencies which require supplementation at least 2 weeks prior and following their body-contouring surgery,” Hurwitz adds. “We offer our patients a custom-designed powder which can be reconstituted to drink twice daily that contains critical minerals and vitamins, and essential amino acids for wound healing. To expedite wound healing, technicians apply phototherapy, Hivamat therapy, and lymphatic massage starting in the first days after surgery.”

Michelle Dychko, aftercare coordinator at Hurwitz Plastic Surgery in Pittsburgh, says, “Patients should be with a caregiver during the immediate postop phase, when injuries and mental breakdowns are most likely. Psychologically, patients are at their most fragile point and become totally reliant on caregivers for everyday activities. Many have mortgaged their homes or gone into debt to pay for the surgery, and come to question their own judgment in having made this decision.”

The effects of anesthesia, antibiotics, and painkillers combine to overload their systems, resulting in paranoia, hysteria, and other unusual behaviors, according to Hurwitz. The recovery phase can be fraught with anxiety and uncertainty. It can last for weeks or months from the patient’s perspective, and the whole experience is immensely colored by what happens during the aftercare phase.

“They are afraid to look at the jigsaw puzzle that has now replaced their once-familiar bodies and need constant reassurance that they are healing on schedule,” Hurwitz adds. “They are not very inclined to believe the doctor when he assures them all is well.”

During each visit, the patient needs encouragement and guidance to help him or her maintain focus and motivation. “When patients feel that their needs are being attended to, even if complications arise, they manage it more calmly and with less emotional strain,” Dychko adds.

“Conversely,” she continues, “a poor aftercare experience can lead the patient to conclude that the surgery was not worth having.” The support required to see people through recovery should be undertaken by caregivers who demonstrate an enormous capacity for caring and listening.

However, Dychko adds, “I have found that hospital employees, nurses, and aides have great unease and misinformation in dealing with postbariatric cosmetic surgery patients. They need to be educated, oriented, and monitored as caregivers so as to better serve and troubleshoot when difficulties arise.”

Patient Psychographics

Psychological and behavioral preparation is an important aspect of the process from bariatric to body-contouring surgery, yet it is often overlooked. The growing demand for bariatric surgery and related procedures has surpassed the development of standardized protocols to sufficiently prepare patients for the behavioral changes they will face.

During this process, patients undergo a roller coaster of emotional and physical changes. The physician should explain to them in advance that a high level of commitment will be required from them to maintain their new size and shape. They have to learn to rethink food and their former eating habits. For some, these sweeping lifestyle adjustments can be overwhelming.

A history of psychiatric disorders is prevalent among bariatric surgery candidates and may be associated with obesity and lower functional health status.1 There is a growing need among health care professionals to understand potential implications during the postsurgery period.

Failure to maintain the weight loss and the subsequent feelings of inadequacy and guilt can feed an underlying condition. In some cases, in persons with a history of depression, a renewed body image may actually help alleviate some of these symptoms. Some patients turn their addiction to food into an obsession for working out or shopping.

The Path to Self-Acceptance

Weight loss occurs so rapidly that there is often little time for patients to pause and get reacquainted with their diminishing size. As their bodies adjust to a new healthier weight, their psyche may take time to catch up. They still see a fat person, and this smaller body becomes unrecognizable.

Postbariatric patients often experience a feeling of shame when they are heavy, and then feel ashamed when they actually do something about it. At some point during their experience, they may feel like a fat person masquerading as a thin one.

For many patients, a feeling of fraud is manifest when others start to notice their weight loss. In addition to managing their own feelings of change, they must learn to cope with feedback from others, much of which is unsolicited.

Patients who have kept their surgery private may feel awkward when they tell people that they are losing weight just by eating less and exercising more, which may also be true. Patients who speak openly about their weight-loss surgery may face being told that they took the easy way out of obesity.

Getting accustomed to seeing their bodies in a new way can be traumatizing. Most people who have a negative body image do everything possible to avoid looking at themselves in mirrors. It may take time for their bodies to become less central to their self-perception.

Some patients find it easier to adapt to their transformation on the physical rather than the emotional level. After undergoing body-contouring surgery, patients often have conflicting emotions at first. They may feel happy with their body one day, yet sad about the scars the next day. Those who have been overweight for most of their life may have a difficult time adjusting to living at a normal weight.

For patients who struggle with their feelings, talking with a counselor or therapist—or sharing their feelings with a support group—can be a great help. Sharing their personal stories with others who have had similar experiences, and hearing about their struggles and triumphs, can offer the moral support needed to keep patients on track. It is not unlike breast cancer patients who seek solace in a community of other women like themselves.

Personal Relationships

Changes in relationship dynamics are common after major weight loss and body-contouring surgery. Someone who has undergone the bariatric and subsequent body-contouring surgeries has invested a great deal in improving his or her body, including time, money, and a lot of hard work.

It is common to expect a partner, spouse, child, or sibling to be supportive and generally happy for their accomplishments. When that does not happen, disappointment may set in.

It is also common for a relationship with a partner to change, for better or worse. The relationship may improve, with both partners enjoying a fresh new start. If both partners were overweight, the second partner may choose to undergo weight-loss or body-contouring surgery as well. The relationship may also not survive, and they may choose to go their separate ways.

If two people are in a codependent relationship—when they are bound together because neither believes that he or she is able to cope alone—when the obese partner achieves a normal weight, the other partner may experience a fear of abandonment. The act of caring for an obese spouse gave the partner a life purpose, and now there is a void. Feelings of jealousy and anger can also develop when the partner of the patient undergoing treatment grows concerned that his or her newly healthy spouse is now attractive to other people and may be tempted to stray.

Friends may not be able to adapt to the patient’s new appearance and lifestyle changes, and they may eventually drift away. At the same time, a more active lifestyle and changing priorities can create many opportunities to meet new people. Many patients relate that they are able to expand their circle of friends after having body-contouring surgery, after years of reclusive behavior and staying at home.

Despite any conflicting feelings they may exhibit after undergoing body-contouring surgery, most patients claim to experience a boost in their confidence and self-image. The vast majority of patients are thankful to be able to lead a more active life, unencumbered by the physical limitations that previously held them back. Body contouring after bariatric surgery has been shown to improve both quality of life and body image.

“For most patients, the road from disabling obesity to a healthier and more attractive body is a long one, but most are more than willing to take that journey,” Hurwitz says. “When it’s over, patients generally tell us that every step along the way was more than worth it. They feel younger, more attractive, and much happier.”

Future Innovations

The introduction of less invasive forms of bariatric procedures, such as the Lap-Band® and the Bio-Enterics Intra-Gastric Balloon, will continue to attract new patients to this evolving specialty. New research is focusing on endolumenal surgery, which involves going through the mouth endoscopically to operate within the space of the stomach, without the need to make incisions. This could allow surgeons to perform gastric bypass procedures from the inside in the near future.

See also “Choose Wisely!” by Wendy Lewis in the May 2007 issue of PSP.

Among the recent innovations in postbariatric body contouring, the use of self-retaining systems for tissue approximation is showing promise in improving cosmesis and recovery. Operating time is frequently quite long for postbariatric body-contouring procedures, so saving time is important and may reduce complications and trauma for the patient.

Malcolm Paul, MD, a clinical professor of surgery at the Aesthetic and Plastic Surgery Institute, University of California, Irvine, explains, “The use of this innovative technology has been shown to reduce operative time for incision closure by as much as 30%. The number of sutures required to close these typically long incisions is less, knot tying is avoided, and a third hand is not required to follow the suture. The even distribution of tension along the full length of the incision provides an opportunity for horizontal incision-length shortening and seems to produce thinner scars.”

Each new development is redefining the benefits and expanding the prospects for patients seeking post–massive-weight-loss body-contouring procedures.

Wendy Lewis is a contributing writer for Plastic Surgery Products; author of America’s Top Cosmetic Doctors (Castle Connolly); and the editorial director for MDPublish.com, a medical marketing and publishing group. She can be reached via her Web site, www.wlbeauty.com.

REFERENCE

1. Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164:328–334