The obesity pandemic has resulted in increasing cases of bariatric surgery and subsequent issues related to excess skin and laxity for patients. This patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the issues of the body contouring candidate and provides tools that may assist in surgical planning.

Keywords

Body contouring

Bariatric surgery

Skin laxity

Weight loss

Skin excess

Nutritional evaluation

Key points

Introduction

As a result of the obesity pandemic, more and more individuals are seeking bariatric surgery for weight loss and resolution of conditions related to obesity. As the numbers have risen to greater than 200,000 cases per year, the number of postbariatric massive weight loss patients presenting to the plastic surgeon for body contouring to address excess skin laxity is increasing.1 However, this patient population requires unique insight and consideration as part of the preoperative evaluation. Nutritional derangements are common, psychosocial issues are prevalent, and the sequelae of past and present medical conditions can all affect surgical planning and outcomes. This article familiarizes the plastic surgeon with the body contouring candidate and provides tools that may assist in surgical planning.

We have identified six key assessment points as part of a comprehensive evaluation of the massive weight loss patient presenting for potential body contouring surgery: (1) time from gastric bypass to body contouring procedures; (2) body mass index (BMI) at presentation; (3) evaluation of medical comorbidities; (4) nutritional assessment; (5) psychosocial status; and (6) physical deformities and potential for combined procedures. An overview of these points is presented in Box 1.

Preoperative evaluation and procedure timing

Initial preoperative history should focus on age of onset of obesity, family history of obesity, type and date of bariatric surgery performed, and course of weight loss since surgery. Anthropometric measures should include height, weight (highest, lowest, and current), and BMI. Determination regarding patient’s weight stability should be made because many patients have a 12- to 18-month period of continued weight loss after their bariatric surgery. Inquiry into weight changes over the past 1 and 3 months before presentation should be made as part of the patient’s history. We define weight stability as no more than an average of 5 lb/month loss over 3 months. A patient still undergoing significant weight loss may be in a state of protein-calorie deficiency and consequently may be at risk of suboptimal wound healing. Those deemed not stable are delayed and reevaluated in 3 months. An overview of our timing of surgical planning is provided in Box 2.

Patient BMI

Provided the patient has achieved weight stability, evaluation of BMI can be an indicator of potential complications and aesthetic outcomes. We consider patients with BMI less than 30 kg/m2 to be the best candidates for a wide range of procedures and combinations thereof.2 A prospective study of 511 postbariatric body contouring cases revealed that higher prebariatric maximum BMI and BMI at time of presentation were associated with increased complications in patients undergoing single procedures.3 Similarly, the degree of change between these two measures (maximum BMI and BMI at time of presentation) was found to be...