What is Body Contouring?
For most cosmetic surgery patients, body contouring surgery means a tummy tuck or liposuction. Our web pages on these areas provide a basic explanation of these common procedures. Most of these pages are devoted to providing information on the more complex problems of the massive weight loss (MWL) patient, where high-quality information for the public is particularly lacking. The standard non-MWL procedures are smaller, drastically simpler versions of the procedures described in the body contouring section of this website.
The Massive Weight Loss Patient
In recent years, we have been seeing an increasing number of patients who have lost 100 lbs or more. These "massive weight loss" (MWL) patients present a particular challenge in body contouring surgery. The old standard body contouring procedures did not achieve good results when applied to the MWL patient. Only in recent years have we developed new and special techniques for treating the MWL patient. Dr. Borud has been and continues to be an innovator and a leader in this field of plastic surgery on the national and international levels..
Gastric bypass procedures have become far more commonplace in the last few years. Over 160,000 bariatric operations (mostly laparoscopic gastric bypass or lapband) were performed in the United States last year alone. These patients are benefiting from reduction in diabetes, arthritis, hypertension, and other serious medical problems of obesity. Many if not all such patients are left with tremendous amounts of excess skin when their weight loss is completed – usually about a year or so after the gastric bypass procedure. In most patients, the skin had been stretched beyond its elastic limits during their period of obesity. In other words, no amount of muscle “toning”, lifting, gym work, further weight loss, or other activity will adequately rid the patient of this skin excess. Patients, friends, and family members are frequently under the misconception that the MWL patient can simply "work off" the skin excess. Often, the excess skin can cause medical problems including rashes and infections under the "pannus" in front. It can also prevent the patient from wearing appropriately fitting clothing.
Here at BIDMC, we have an extensive experience here in body recontouring after gastric bypass including panniculectomy (removal of excess abdominal skin), brachioplasty (removal of excess upper arm skin), breast lift, thigh lift, lower body lift and neck lift. Our web site covers these procedures individaully, and we encourage you to browse through the procedure-specific pages.
Financial Considerations for Body Contouring
One question that commonly arises is whether third-party payors will cover some or all of the body contouring surgery. In our experience, insurance will sometimes cover the panniculectomy (removal of skin in the front of the abdomen only), but will not cover other any other procedures in the buttock, thighs, breast, mons, arms, or back. During your evaluation, we will take photos and perform a detailed analysis of the areas of concern. Our office will write a letter to your insurance company requesting preauthorization for the panniculectomy portion of the surgery if there is a realistic probability of coverage based on criteria and our experience with various payors. The insurance company will then let us know whether or not they will “cover” the panniculectomy. In the usual case, most or all of the planned surgery is cosmetic, and not covered by insurance. Thus, part of every consultation is a meeting with our financial counselor and division administrator Jennifer. She will provide a detailed fee quotation including the surgeon fee, hospital fee, and anesthesia fee.
Risk and Informed Consent
The benefits of the surgery are obvious to everyone. But part of the consultation is about informing you of the risks of surgery. Minor complications are common while major complications are rare. During your visit, we will go over the risks and benefits in detail of the various skin removal procedures that may apply to you. In my experience, the vast majority of patients are very happy with their surgery. However, skin removal procedures are associated with lengthy, sometimes obvious scars. It is also usually impossible to safely remove all of the excess skin in a particular area or completely flatten the abdominal contour. Because of anatomical considerations, gastric bypass contouring procedures also carry with them a higher rate of wound infections and wound breakdowns, especially in the lower abdomen and groin areas. These can present a temporary aggravation, but rarely cause significant illness or substantially affect the outcome of the surgery. The "touch up" rate is high - about 20% or so - because of the complex nature of the skin excess. The "major" complication to worry about is a blood clot in the leg or lung. We take all measures to prevent that, including giving the patient a take-home kit to inject once-a-day blood thinner for a week after surgery. In hundreds of cases, I have had only two blood clots to the lungs, and both patients are alive and well!
A Few Words about the Abdomen in MWL Patients
The #1 area of concern for most gastric bypass patients is the lower abdomen. Sometimes a hernia is present from the gastric bypass procedure, if it was done as an open operation. This is quite common, and we can repair the hernia at the same time as removing the excess skin (panniculectomy). The incisions and operative technique are similar to those I have described in the “abdominoplasty” or “tummy tuck” area. Usually, patients need to stay 2 nights overnight in the hospital, especially if they have a hernia repair at the same time. If you have a vertical scar from the gastric bypass, we usually remove it, along with some excess central skin. Thus, the resulting scar is an inverted “T” shape.
In gastric bypass patients, as opposed to other patients having a “tummy tuck”, the skin excess is usually quite extensive, and extends circumferentially around the back. The best cosmetic outcome for the trunk is to combine the “panniculectomy” (which removes frontal skin) with abdominoplasty (which adds the cosmetic features around the belly button and tightening of the muscles) and a buttock/outer thigh lift. This is a lower body lift, which removes skin all the way around the back. Even though this creates a longer scar, it allows us to distribute the horizontal skin excess around the back. This can almost always avoid the need for the inverted “T” type scar in the middle of the abdomen or lateral take-out procedures at a second stage. Especially in patients who have had the laparoscopic gastric bypass and do not already have a vertical abdominal scar, the lower body lift is a good alternative to the simple panniculectomy/abdominoplasty. One practical problem is that, even if insurance does cover the frontal skin removal (panniculectomy), we have had no success in getting insurance coverage for the lower body lift.
Other areas of skin excess that are frequently addressed in the post gastric bypass patient are the breasts (breast lift or “mastopexy” in women, with or without additional breast augmentation), arms (upper arm lift or “brachioplasty”), thighs (thigh lift), and the male breast. Browse our website for more details.
Your Body Mass Index
You can calculate your own body mass index (BMI) by typing your height and weight into an online calculator. This figure is very important for the surgeon and the patient. The lower the BMI, the better results we can achieve in your particular case, and the lower the complication rate. When you look at before and after photos on the internet, take careful note of the BMI to see if this is comparable to your situation. If your BMI is over 32, you are probably not a candidate for any body contouring surgery. If your BMI is 28 or less, you stand to achieve potentially excellent results from body contouring surgery.