Total Body Contouring:
Reshaping After Bariatric Surgery
As obesity continues to reach epidemic proportions in the United States, bariatric surgery is becoming a more common technique for long-term treatment of obesity. Bariatric surgery is a method of weight loss for the severely obese (with a body mass index of 30 or higher), who have been unable to lose weight by any other means.
According to J. Peter Rubin, MD, assistant professor of surgery and director of the Life After Weight Loss Program at UPMC, “Bariatric surgery has evolved as the only truly effective and reliable treatment for morbid obesity, resulting in dramatic weight loss for patients over a period of time. As the surgery gains popularity, more people are deciding to undergo the procedure.”
In 2004, nearly 140,000 Americans had bariatric surgery. Of those, approximately 2,000 cases were performed in Pittsburgh, distinguishing it as a major center for weight loss surgery.
The success of bariatric surgery has created the need for a new surgical specialty — total body reshaping, or body contouring — which is performed as a service of UPMC’s Life After Weight Loss Program. The program has been in existence for five years and cares for as many as 50 body-contouring patients each month.
“Advances in technology and in the surgical care of severely obese patients have allowed for improved outcomes, shorter hospital stays, and improved long-term well-being following surgery,” says Anita Courcoulas, MD, director, Minimally Invasive Bariatric and General Surgery at Magee-Womens Hospital of UPMC.
After bariatric surgery, a patient likely looks better, feels better, and begins a whole new lifestyle. While most changes are positive, such as the ability to enjoy shopping for clothes, sitting in a movie theater, and becoming more physically active, some results are challenging. “When a person loses a tremendous amount of weight, he or she may encounter a problem with excess skin, which affects appearance, comfort, and hygiene,” says Dr. Rubin.
Hanging skin also may be a constant — and unwelcome — reminder of past obesity. “As a patient tries to obtain a new body image and release the memory of being obese, excess skin may be a daily reminder of the former self,” says Dr. Rubin. “For many patients, total body reshaping represents the completion of the weight loss journey.”
The best time to consider body contouring usually is about 12 to 18 months after bariatric surgery — when a patient is as close as possible to his or her goal weight . Experts at UPMC’s Life After Weight Loss Program prefer patients to be at stable weight for at least three months before considering surgery.
It is hard to predict who will have problems with hanging skin, because the way the body looks after weight loss surgery is directly related to the unique ability of each person’s skin to shrink over the new, slimmer foundation. The more elastic the skin, the better it conforms to the new body shape. Normally, skin that was stretched the most from weight gain will be the least elastic after weight loss. Age, sun exposure, cigarette smoking, and genetic factors also may play a role in decreased elasticity.
While loose skin after weight loss can affect all parts of the body, the belly is the most common area of concern. Excess skin under the breasts, or on the thighs, back, or upper arms also may cause significant discomfort and embarrassment.
UPMC plastic surgeons have special expertise in body contouring of the abdomen, chest and breasts, arms, buttocks, thighs, face, and neck. The decision to undergo plastic surgery procedures after weight loss may be influenced by a patient’s current weight, other medical conditions, and financial situation.
“Because many patients have excess skin all over, plastic surgeons have had to reinvent some basic body contouring operations and even develop new ways to deal with excess skin,” says Dr. Rubin. “We are working on parts of the body not typically addressed by plastic surgery, such as the upper back and the side of the chest.”
Common techniques include:
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Tummy tuck, also known as an abdominoplasty or panniculectomy, is the most common post-weight loss procedure and ranges from removing the apron of skin (pannus) to a complete contouring of the abdomen, including the tightening of the abdominal muscles and moving the belly button.
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Hernia surgery can be performed in conjunction with tummy tuck procedures to fix hernias that are present.
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Liposuction uses small, narrow tubes to remove fat and is often used in combination with other lifting procedures to help achieve better contouring in various parts of the body.
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Armlift, or brachioplasty, can remove loose skin and give the arm a nice contour. However, the procedure may leave visible scars along the upper arm to the elbow. Patients must consider whether they are willing to tolerate scars in return for slender, shapely arms.
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Thigh and buttock lift involves a spectrum of operations customized to individual needs. The outer thighs can be lifted when a tummy tuck is performed, or, the thighs and buttocks can be lifted in a separate procedure.
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Breast reshaping operations come in many forms, but all have the common goal of achieving better size and proportions. This technique removes skin and breast tissue while moving the nipple to a higher position. Although some scarring will occur, it usually is covered by bras or bathing suits.
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Male breast reduction, or gynecomastia, is a treatment that involves a combination of liposuction and skin removal. Any scarring usually is well-concealed by chest hair.
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Facelift or necklift can correct loose skin on the neck or face. Scarring from these procedures usually is hidden along the front of the ear and in the hair.
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Upper body lift corrects rolls of skin on the back and sides. Plastic surgeons specializing in total body reshaping often develop unique procedures which focus on these difficult areas, which are often difficult to correct.
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Lower body lift is the cornerstone of total body contouring, according to Dr. Rubin. A combination of an abdominoplasty, plus a thigh and buttock lift, it requires an incision all the way around the belt line to lift and reshape the entire lower body and torso. The surgery is typically combined with upper body lift and, for women, breastlift procedures.
“There are various approaches to body reshaping after bariatric surgery,” says Dr. Rubin. “Some patients require only a single procedure such as a tummy tuck, armlift, or breastlift, while others select complete total body contouring, which often takes place in stages.”
Many body-reshaping techniques, including a new breastlift procedure which now is being performed by surgeons nationwide, have been pioneered at UPMC. In addition, the surgeons at UPMC have made technical refinements to the lower body lift.
More than surgery
In addition to body contouring, the Life After Weight Loss Program partners with the UPMC Weight Management Center to provide counseling on lifestyle and behavioral change, nutrition, exercise, and stress reduction, as well as medical management of long-term weight loss.
The UPMC Weight Management Center is committed to helping people achieve long-term weight loss goals and live healthier lifestyles. Using a comprehensive approach, the Weight Management Center team, led by Madelyn Fernstrom, PhD, provides one-on-one lifestyle counseling and professional support, in addition to guidance about nutrition and exercise. The UPMC Weight Management Center draws expertise from several specialty areas within UPMC, including gastroenterology, pulmonary medicine, preventive cardiology, plastic surgery, endocrinology, clinical nutrition, exercise physiology, sports medicine, complementary medicine, and psychiatry. This multidisciplinary approach has helped many patients reach their goals.
The center also conducts ongoing research studies and implements new treatment strategies to provide the latest in weight management care. An integral part of the program is a focus on support groups and education. Programs include counseling on a variety of topics, including nutrition, body image issues, exercise, and behavior change, as well as the medical management of the surgical weight loss patient. Monthly support groups help patients maintain their new shape and reach new personal goals.
“We offer access to a family of services that provide ‘one-stop shopping’ for all weight management needs. We have a comprehensive network of specialized, uniquely trained clinicians throughout UPMC, who provide convenient and practical solutions for weight loss needs. Working together with the Life After Weight Loss program, we partner with patients for life to help them manage their weight and meet their goals,” says Dr. Fernstrom.
Advancing outcomes
UPMC researchers have established a unique and comprehensive database to monitor the long-term success of weight loss patients after body contouring surgeries. They are pioneers in studying the body image of patients after weight loss surgery and body contouring, and in understanding the impact these changes can make in daily life. “We enter medical data, with patients’ consent, into a database to analyze how well we’re doing with body contouring results and learn how we can improve future methods,” says Dr. Rubin.
Researchers also are conducting cellular studies in adipose (fat) tissue, which will enhance understanding of how fat cells function in the body. “There are cells within fat tissue that behave like and represent adult stem cells. Amazingly, these stem cells can be transformed in the laboratory into a variety of tissues such as those found in bones, cartilage, and muscle, as well as in the blood system and liver.”
These useful fat cells are harvested in large quantities through liposuction, which is minimally invasive, and a common procedure already being conducted during body reshaping. Adult stem cells are not the same as embryonic stem cells and usually are used for different applications.
Fat cells also are used to make more fat, which may be injected as part of reconstructive plastic surgeries for trauma or cancer patients. In the future, these cells may be used to stimulate new tissue growth after heart attack or stroke.
For referral to the Life After Weight Loss Program or the UPMC Weight Management Center, call 1-800-533-UPMC (8762).