The Art of Body Contouring: After Massive Weight Loss (eBook)

The obesity epidemic continues to evolve into the greatest public health concern facing this generation. As a result of the rising incidence of obesity worldwide and the adoption of laparoscopic bariatric surgery techniques, there has been an exponential rise in the number of bariatric procedures performed during the past decade. Bariatric surgery continues to be the most effective treatment for morbid obesity; currently more than 300,000 bariatric procedures are performed annually worldwide. Although bariatric surgery results in massive weight loss, the sequelae of redundant skin and adipose tissue can significantly affect the patient’s quality of life and satisfaction. Body-contouring surgery therefore represents an important component of comprehensive care for patients undergoing bariatric surgery. A plastic surgeon performing body-contouring surgery must understand the spectrum of bariatric procedures available to patients as well as the anticipated trajectory of weight loss, nutritional issues, and some of the potential complications that can occur with these operations. Surgeons should also have a comprehensive understanding of the disease of morbid obesity and its associated physiologic and psychological health issues. This chapter will outline modern bariatric surgical practices and their implications with respect to body-contouring surgery.

Prevalence of Obesity

Obesity is a disease state that is increasing in incidence and that carries with it a significant health burden, despite the recognition of obesity as a major public health problem and a call to action among developed nations for more than a decade. Since 1980, the incidence of individuals who are overweight or obese has increased threefold in certain regions of North America, Europe, New Zealand, Australia, and Asia. Even developing countries such as India, China, South Africa, Argentina, Guatemala, and the Pacific Islands have been increasingly affected by obesity. Both the National Institutes of Health and World Health Organization have reported that obesity as defined by BMI criteria has been steadily increasing over the last three decades at an average rate of 0.3 to 0.8% per year. Obesity prevalence has risen to such great heights in the United States that currently more than one-third of American adults are considered obese (BMI >30 kg/m2) and 5.9% are considered morbidly obese (BMI ≥40 kg/m2). The percentage of people who are morbidly obese is more than double that identified during the 1970s. The morbidly obese group seems to be becoming increasingly prevalent compared with the more moderate classes of obesity. It is expected that 75% of Americans will be overweight by 2025. The prevalence of obesity has increased in both males and females of all ages, in all racial and ethnic groups, and among individuals of all educational levels. The world prevalence of overweight adults is estimated at more than 1.6 billion, with more than 400 million of those individuals considered obese. The World Health Organization predicts that there will be more than 2.3 billion overweight adults and 700 million obese individuals worldwide by 2025.

Associated Health Problems and Societal Impact

Obesity has a widespread effect on an individual’s overall health. It has been noted as a major risk factor for a host of health problems, including hypertension, type 2 diabetes, dyslipidemia, cardiovascular disease, and obstructive sleep apnea. It has also been implicated in the development of various malignancies, including breast, colon, prostate, and endometrial cancer. As a result, obesity is on its way to overtaking tobacco use as the main cause of preventable deaths in the United States. It currently contributes to approximately 300,000 premature deaths each year.

Obese patients can be placed in graded categories of obesity on the basis of their BMIs. The relative risk of death increases substantially with increasing BMI, particularly for individuals who have BMIs of ≥35 kg/m2 (severe obesity). Studies have found that mortality rates among the morbidly obese (BMI >40 kg/m2) are 2.5 to 12 times higher than those of individuals of normal weight. Although there appears to be a direct correlation between climbing BMI and mortality, this relationship is likely more complex. Underlying genetic factors as well as other anthropometric indices (e.g., hip–waist circumference) may better define obesity-related risk in the individual patient (Table 1.1).

Table 1.1 Categorization of body mass index measurements

The financial burden that results from the treatment of obesity and its related illnesses is immense. In the United States, the cost of the management of obesity and its related conditions has been estimated at $150 billion annually. This high cost is further complicated by a health care climate of finite resources and climbing expenditures. The management of obesity and the prevention of its related health problems has already become an important focus of public health care legislation and policy initiatives. Because we have not yet reached the pinnacle of the obesity epidemic, strategies for the prevention and management of obesity will become increasingly important. As more patients are afflicted with obesity, we can anticipate bariatric surgery becoming increasingly prominent in the future.

Treatments for Morbid Obesity

DIETARY, EXERCISE, AND BEHAVIORAL MODIFICATIONS

Currently the Centers for Disease Control and Prevention (CDC) recommends assessment of weight by BMI category. The goal of most weight loss strategies is to achieve a 1- to 2-pound loss per week until the weight is in the target healthy BMI zone (18.5–24.9 kg/m2). Evidence would suggest that nonsurgical approaches to weight loss in the form of diet, exercise, and behavior modification have modest success in the short term, but weight loss by these methods alone does not appear to be durable and often fails over the long term. In a systematic review of major weight loss programs in the United States, it was found that 15 to 25% of weight loss was seen over the short term (3–6 months), but less than 9% of patients were able to maintain their weight loss at 1 year. Another review of randomized controlled trials of weight loss involving very-low-calorie diets with 12 to 36 months of follow-up reported losses that ranged between 3.5 and 13.4 kg; long-term weight loss data were not available. There have been some studies with long-term follow-up that have demonstrated significant major weight loss in the short term (≤100 pounds). These studies employed intensive behavioral interventions (residential nursing programs, weight-loss camps, outpatient courses featuring weekly meetings, midweek phone calls, and close staff follow-up) and were quite expensive, thereby making them cost prohibitive for the majority of obese individuals. Despite these efforts, most of the studied patients had regained 34 to 41% of their lost weight at 1 to 5 years of follow-up.

MEDICAL MANAGEMENT

There are a large number of anti-obesity medications in preclinical development, although none have yet proven to be the elusive panacea for weight loss. The criterion currently used by the U.S. Food and Drug Administration (FDA) for measuring the efficacy of appetite-suppressing drugs is the demonstration of statistically significant weight loss. This is considered weight loss that is 5% better in the treatment group than in the placebo group according to data from a randomized, double-blind, placebo-controlled clinical trial. Currently those patients who are unable to lose weight through diet, exercise, and behavioral modification alone who have a BMI of more than 30 kg/m2 or of more than 27 kg/m2 and a comorbid condition are eligible for drug treatment. Sibutramine (a serotonin reuptake inhibitor) and orlistat (a lipase inhibitor) have both been used as pharmaceutical adjunctive agents for weight loss therapy. Sibutramine was removed from the European market because of a significant number of reported adverse events, including tachycardia, hypertension, and arrhythmias; it was subsequently removed from the U.S. market as well. Another medication, rimonabant, has been approved in the United Kingdom for weight loss and weight loss maintenance. These medications have demonstrated short-term successes involving the loss of 5 to 10% of body weight from baseline. In addition to the various side effects associated with orlistat (loose stools, flatulence), psychiatric disturbances associated with sibutramine have been described.

BARIATRIC SURGERY

Bariatric surgery has undergone a dramatic evolution since its inception. The tenets of ­restriction and malabsorption were central to a variety of surgical operations described during the last three to four decades, although it has become apparent throughout the course of this evolution that the mechanisms behind bariatric surgery are much more...