INTRODUCTION
The prevalence of overweight and obesity is increasing globally. More than one in
10 persons worldwide is obese and it is believed that 2.2 billion people are
overweight, causing millions of deaths per year1,2. Brazil ranks
fifth in the world ranking of this disease, with about 60 million overweight
people and 22 million obese people, which corresponds to 17% of its
population3.
Obesity leads to increased mortality due to the risk of other diseases, such as
diabetes mellitus type 2 (DM2), systemic arterial hypertension (SAH),
dyslipidemia, sleep apnea, cardiovascular diseases, and certain types of
cancers, besides undeniable discomfort and a low quality of life (QOL) due to
body deformity4. Bariatric surgery
provides, in addition to sustained weight loss, additional benefits to people
with obesity-related comorbidities and reduces the relative risk of death in
these patients5,6. Consequently, the demand for surgical
treatment of this disease has increased significantly in recent years.
The weight reduction achieved after bariatric surgery is around 40% to 60% of the
initial weight and may result in deformities in several body parts.
Consequently, some patients have excess skin that can cause problems related to
movement, wearing clothes, dermatitis, changes in posture, psychological
problems, poor self-esteem, and a low QOL as a result of the surgery3.
Due to the need to remodel the body contour, body contour surgery is performed.
It is defined as a reconstructive and functional surgery. Data from the
literature indicates that more than 70% of patients with massive weight loss
seek this type of procedure to improve their quality of life7,8.
OBJECTIVE
The present study aims to describe the routine planning, marking and method of
execution, and the results of plastic surgery at Daher Lago Sul Hospital
performed for post-bariatric body contour surgery cases, describing the
two-level principle.
METHODS
This is a retrospective, longitudinal, observational study conducted at the
Plastic Surgery Department of Daher Lago Sul Hospital, Brasília - Federal
District, from March 2015 to April 2017.
This research paper followed the legal guidelines approved by the Resolution
196/96 of the National Health Council with regard to research involving human
beings and in accordance with the principles of the Declaration of Helsinki.
This study followed a nonrandom sample selection technique and was based on
whether post-bariatric lower and/or upper level lift procedures were
performed.
The inclusion criteria in the study were:
1. Ex-obese patients with stable weight for a minimum of 6 months and body
mass index (BMI) between 18.5 and 29.9 kg/m2;
2. Presence of body contour deformities arising from weight loss in the
lower and/ or upper parts of the body;
3. Patients classified as ASA 1 or ASA 2 according to American
Society of Anesthesiology criteria.
The exclusion criteria were:
1. Stable weight for less than 6 months;
2. BMI > 29.9 kg/m2;
3. Patients classified as ASA greater than or equal to 3.
The variables evaluated were sex, age, weight loss after bariatric surgery,
surgery time, time between the first and second surgical procedure,
post-operative surgical complications, weight of the patient, BMI, and length of
hospital stay.
The patient’s level of satisfaction with the surgical outcome was assessed during
post-operative follow-up visits. The patients responded whether they were
satisfied or not satisfied with the procedure.
A comparative analysis of pre-operative and at least 2 months post-operative
photographic images was performed by a plastic surgeon associated with the
Brazilian Society of Plastic Surgery (BSPS) who did not participate in the
surgical procedures, and the results were classified as great, good, fair, and
poor.
Surgical Technique
The surgery was divided into 2 stages according to protocol: lower level
(abdomen, lower back, buttocks, and thighs) and upper level (upper back,
breasts and arms). The order of the procedure was variable, according to the
patient’s complaints; but always performed in two stages, and according to
the patient’s preference to start with either the lower or upper level.
The markings were always performed with the patient in the orthostatic
position initially, and then completed in dorsal, ventral, and seated
positions.
General anesthesia was routinely used. Asepsis and antisepsis were always
performed 360 degrees, allowing for a change to a decubitus position at the
operating table, according to the surgical procedure and was performed
sequentially, shortening the surgical time. The legs were also bandaged to
prevent venous thrombosis. Antibiotic prophylaxis with 1 g of cefazolin was
routinely administered, and was repeated if the surgery exceeds 4 hours.
The surgical team consisted of at least 5 members, including the primary
surgeon, with at least 3 assistant surgeons, and a surgical technician.
Lower body:
A solution of saline and adrenaline (1: 500,000) was administered with 2
ampoules of 2% lidocaine.
The procedure started with the patient in the ventral decubitus position and
a “gull wing” incision was performed (or with a dorsal incision facing
upwards, if there were large, well-defined folds in the back) limited up to
the previous mark. A liposculpture of the back and/or flanks was initially
performed, followed by a detachment of the suprafascial dermal-fat flap. The
dermal-fat tissue resection was marked with an excess flap marking clamp,
while checking the previous pinch test mark. The pinch test was performed
without any deformation of the genitalia as described by Roxo9,10. Sutures were placed in two planes with nylon
threads.
When the patient was changed to a dorsal decubitus position, we began
liposuction of the anterior abdomen, with all the aspirated fat conditioned
for the indicated lipografts and refinement of the final result.
Subsequently, abdominoplasty was performed.
The patient was then placed in a dorsal decubitus position for either a
“classic” or an “anchor” (depending on tissue surpluses and existing scars)
abdominoplasty. An incision was made in the lower abdomen while taking
special care of any detachment, which should be very restricted in the
lateral areas, especially in cases where there was liposuction as described
by Saldanha11. A plication of rectus
abdominis muscles was performed with nylon threads; followed by an
umbilicoplasty using the skin mini-circle technique12, caudal traction of the abdominal flap, resection of
surplus dermal-fat tissues, and approximation of the planes by means of
Baroudi’s adhesion points13. Vacuum
drains were routinely used and externalized by minimal incisions in the
inguinal folds. Sutures were placed according to the anatomical planes with
nylon threads.
Next, an incision was performed in the crural region at the inguinal area up
to the subgluteal fold (which could extend to the sides of the thigh in
cases of large riding breeches) and added to the vertical incision on the
inner thighs (which extended to the knee joint if required), followed by
suprafascial detachment, and resection of the dermal-fat surplus (determined
by the pinch-test maneuver and confirmed with the flap withdrawal marking
clamps). Sutures were then placed according to the anatomical planes with
nylon threads. Particular attention was paid not to deform the genitalia
while performing a cranial traction of the flaps and their anchorage. The
deformity was verified with the thighs in adduction and abduction
positions.
Upper body:
A solution consisting of saline (1: 300,000) with 2 ampoules of 2 % lidocaine
without a vasoconstrictor was applied to all the areas to be operated.
A torsoplasty was performed with the patient in the ventral decubitus
position, in the indicated cases. The pinch test maneuver was performed and
any surplus tissue from the upper back was resected, while trying to place
scars on the breast topography when possible (in the case of female
patients). It should be remembered that dorsal scars in the lower body tend
to rise, and upper dorsal scars tend to lower in the medium-term
post-operative period.
The 360-degree incisions do not always cross the spine. In this region,
especially in the lower dorsal area, the closure should be of very low
tension, avoiding wound dehiscence.
The patient was moved to a dorsal decubitus position and breast markings were
performed (using the Pitanguy technique). Mammoplasties during these
procedures usually have indications for associated silicone implants, which
were always placed retroglandular, respecting the principle of a “tight
skin”. Round and textured silicone implants were routinely placed in the
retro-glandular position and the rise of areola-papillary plaques was
performed using the classic Pitanguy technique, with adaptations for flap
ascension when necessary by the Skoog, Silveira Neto, or areola plug
flap
10 technique. Next a brachioplasty
was conducted, beginning with liposuction of the flaps in the suprafascial
area, with an incision in the medial face of the arms, an anterior incision
in the topography of the brachial sulcus, and a suprafascial detachment and
resection of the dermal-fat surplus (verified by the resection marking
clamp). Sutures were placed in the anatomical planes with nylon threads.
The brachioplasty incision may be continuous with the sub mammary sulcus
incision, to develop bilateral upper back traction. Therefore, in cases
where it is indicated, a 360-degree dorsal incision should be avoided.
Pre and post-operative care
Pre-operative
All the patients underwent laboratory tests (including serology for HIV,
hepatitis B, and hepatitis C), cardiac and anesthesia evaluation prior
to the procedure, with the approval of the bariatric surgeon to perform
the restorative surgery.
Abdominal wall imaging (computed tomography or ultrasonography) was
performed in all the cases to detect any change. In women who underwent
upper level surgery, due to the mammary approach, a mammography
ultrasound and mammography or a complete breast cancer prevention
protocol was also conducted.
Post-operative
An intravenous infusion of 1 g of cefazolin was maintained every 8 hours
for as long as the patient was hospitalized. After discharge, 500 mg of
cefadroxil was prescribed orally every 12 hours for 7 days.
All the patients were strongly encouraged to ambulate early and were
instructed to bend their legs and perform feet flexion and extension
movements before the surgery. A subcutaneous infusion of 40 mg of
enoxaparin, was started 10 to 12 hours after the surgery and was
maintained for 6 more days, with one dose administered every 24
hours.
Surgical overalls were worn by the patients from the first post-operative
day and maintained for at least 30 days. The use of isolated surgical
bras was avoided post-mammoplasty with silicone implant to prevent of
cranial mobilization of the implants.
The patients were allowed to take baths with running water on the first
post-operative day. The surgical wounds were washed with bactericidal
soap and 70% alcohol was applied until they were completely healed. The
drains were maintained until the flow rate was less than 60 mL/24
hours.
All the patients were instructed not to expose themselves to the sun
until all bruises were absorbed. After this period, they were allowed to
perform all physical activities, including sun exposure.
In addition, a protein rich diet was prescribed.
After hospital discharge, the patient returned to the clinic weekly until
all external stitches were removed and all the wounds healed. Outpatient
reviews were performed 30, 90, 180, and 365 days post-surgery for
reevaluation and photographic records.
Statistical Analysis
The results were imported into Microsoft Excel 2008 spreadsheets and analyzed
in the Epi Info program, version 3.5.1. A descriptive data analysis was
performed, and the results were represented as frequencies.
RESULTS
Thirteen patients were analyzed, including 10 women and 3 men. Seven patients
underwent only lower level surgeries and the other 6 patients underwent lower
and upper surgeries (at different times).
The ages ranged from 30 to 59 years, with a mean age of 44 years. The weight loss
after bariatric surgery ranged from 26 to 122 kg, with a mean of 66.11 kg. At
the time the patients underwent post-bariatric surgery, the mean BMI of the
patients was 26.15 kg/m2.
The mean surgery time on the lower level was 4 hours and 54 minutes. The mean
operative time of upper level surgery was 4 hours and 5 minutes. The time
elapsed between lower level and upper level surgeries ranged from 6 to 10
months, with a mean of 8 months.
If the procedures on each part of the body were performed separately and by a
single team, the approximate times were:
4. Abdominoplasty: 4 hours
5. Mammoplasty: 3 hours and 20 minutes
6. Brachioplasty: 3 hours (1 hour and 30 minutes on each side)
7. Cruroplasty: 3 hours (1 hour and 30 minutes for each side)
The total time taken for all the procedures together was 13 hours and 20 minutes.
Therefore, room hours (costs and security) of approximately 9 hours was saved in
addition to a decrease in the amount of patient isolation time due to repeated
surgeries.
Out of all the cases, 8 patients (61.53%) underwent abdominoplasty with a 360°
incision, and 1 case was performed with a dorsal incision, 3 patients (23.07%)
underwent a conventional incision and only 1 patient (7.69%) underwent anchor
abdominoplasty. Out of all the patients who underwent upper-level surgeries, 4
patients (66.67%) underwent a cutaneous resection in the upper back.
For surgeries performed on the lower level, the weight of surgically resected
tissue from the abdomen and back varied from 1.30 to 3.16 kg, with a mean of
2.37 kg. The weight of the resected tissue from both the thighs ranged from
0.240 to 0.504 kg, with a mean of 0.374 kg. For procedures performed on the
upper level, the weight of the resected tissue from brachioplasty ranged from
0.280 to 0.882 kg, with a mean of 0.554 kg.
The lengths of hospital stay in all the cases did not exceed 24 hours and all
patients were discharged a day after surgery.
Post-operative complications consisted of: 4 cases of small wound dehiscence in
the thighs, 3 cases of small wound dehiscence in the abdomen, and 2 cases of
wound dehiscence in the breasts; all were treated conservatively with serial
dressings. Seromas were observed in 4 cases (2 cases in breasts and 2 in thighs)
and were treated with punctures and lymphatic drainage. One patient had a
clinically treated pulmonary thromboembolism. No surgical complications such as
hematoma, flap necrosis and/or infection were observed (Table 1).
Table 1 - Complications in patients that underwent surgery.
| Complications |
Total |
% |
| Breast dehiscence |
2 |
33,33 |
| Thigh dehiscence |
4 |
30,76 |
| Abdomen dehiscence |
3 |
23,07 |
| Breast seroma |
2 |
33,33 |
| Thigh seroma |
2 |
15,38 |
| Thromboembolism |
1 |
5,26 |
| Pulmonary |
|
|
Table 1 - Complications in patients that underwent surgery.
A total of 92.30% patients reported that they were very satisfied with the final
results obtained with no complaints regarding the size and position of scars.
All the patients who underwent the two-level approach were satisfied with the
surgery (Table 2).
Table 2 - Patient satisfaction after post-bariatric surgery.
| |
Satisfied |
Dissatisfied |
| 2 Levels (lower and upper) |
6 |
0 |
| 1 Level (lower) |
6 |
1 |
Table 2 - Patient satisfaction after post-bariatric surgery.
The results of the procedure were examined by an external evaluator and
classified as great, good, fair, and poor. Out of the 6 cases that underwent
lower and upper level procedures, 2 were classified as great, 3 as good and 1 as
fair. Out of the 7 cases that underwent only to the lower level procedures, 5
were classified as great and 2 were good. Overall, according to the external
evaluator, 53.84% of the cases had a great surgical result, 38.46% were good and
7.69% were fair. No results were classified as poor (Table 3).
Table 3 - Analysis of surgical results by the external evaluator.
| |
Lower + upper |
Lower |
Total |
| Great |
2 (33.33%) |
5 (71.42%) |
7 (53.84%) |
| Good |
3 (50%) |
2 (28.57%) |
5 (38.46%) |
| Fair |
1 (16.67%) |
0 (0%) |
1 (7.69%) |
| Poor |
0 (0%) |
0 (0%) |
0 (0%) |
Table 3 - Analysis of surgical results by the external evaluator.
The images of the cases are given below (Figures 1 to 6).
Figure 1 - Thirty-year-old patient. A, B and C:
Pre-operative images. D, E and F:
Post-operative images after 1 year and 7 months.
Figure 1 - Thirty-year-old patient. A, B and C:
Pre-operative images. D, E and F:
Post-operative images after 1 year and 7 months.
Figure 2 - Forty-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 1 year and 7 months.
Figure 2 - Forty-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 1 year and 7 months.
Figure 3 - Fifty-one-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 1 year and 7 months.
Figure 3 - Fifty-one-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 1 year and 7 months.
Figure 4 - Fifty-nine-year-old patient. A, B and
C: Pre-operative images; D, E and
F: Post-operative images after 3 years.
Figure 4 - Fifty-nine-year-old patient. A, B and
C: Pre-operative images; D, E and
F: Post-operative images after 3 years.
Figure 5 - Thirty-nine-year-old patient. A, B and
C: Pre-operative images; D, E and
F: Post-operative images after 1 year.
Figure 5 - Thirty-nine-year-old patient. A, B and
C: Pre-operative images; D, E and
F: Post-operative images after 1 year.
Figure 6 - Thirty-eight-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 2 years and 4
months.
Figure 6 - Thirty-eight-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 2 years and 4
months.
Patients who underwent lower and upper body surgeries (Figures 7 to 13).
Figure 7 - Forty-six-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 3 years.
Figure 7 - Forty-six-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 3 years.
Figure 8 - Fifty-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 1 year and 6 months.
Figure 8 - Fifty-year-old patient. A, B and C:
Pre-operative images; D, E and F:
Post-operative images after 1 year and 6 months.
Figure 9 - Thirty-nine-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 1 year.
Figure 9 - Thirty-nine-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 1 year.
Figure 10 - Thirty-five-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 3 months.
Figure 10 - Thirty-five-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 3 months.
Figure 11 - Fifty-one-year-old patient. A, B and C:
Pre-operative images. D, E and F:
Post-operative images after 1 year.
Figure 11 - Fifty-one-year-old patient. A, B and C:
Pre-operative images. D, E and F:
Post-operative images after 1 year.
Figure 12 - Thirty-seven-year-old patient. A, B and
C: Pre-operative images; D, E and
F: Post-operative images after 1 year.
Figure 12 - Thirty-seven-year-old patient. A, B and
C: Pre-operative images; D, E and
F: Post-operative images after 1 year.
Figure 13 - Thirty-eight-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 1 year.
Figure 13 - Thirty-eight-year-old patient. A, B and
C: Pre-operative images. D, E and
F: Post-operative images after 1 year.
DISCUSSION
Abdominal adipose tissue resection was first described by Demar and Marx in 1890
in France. Kelly, in 1899, was probably the first to use the terminology
“abdominal lipectomy”, where he performed a transverse dermal-adipose excision
including the navel14,15.
A circumferential abdominal dermolipectomy was described initially by Somalo, in
194016. After decades, Carwell and
Horton described a torsoplasty, which started a new era of technique
enhancement, which also included suspension of gluteal ptosis.
Other authors such as Gonzáles-Ulloa, Baroudi, Pitanguy, among others, described
their techniques for liposuction and developed advances for surgical demarcation
to position the posterior scar properly 15,17.
With the advent of bariatric surgery, and an increase in demand for
dermolipectomy, improved surgical techniques to adapt to new circumstances have
been developed for post-operative bariatric surgery. Currently, multiple
variations of surgical techniques are available to improve body contour14 which are indicated according to the
case.
After bariatric surgery, patients have dermal-fat leftovers distributed in the
anterior wall of the abdomen, and throughout the abdominal circumference.
According to the literature, circumferential abdominoplasty has tremendous
benefits, such as better distribution of the remaining tissues throughout the
trunk circumference, decreased waist circumference, and suspension of the
gluteal region.
Another advantage of this procedure is that the scar can be easily concealed by
intimate clothing. However, in patients with a median longitudinal incision from
conventional bariatric surgery or those with excess dermal fat in the epigastric
region, an anchor abdominoplasty is indicated to obtain a satisfactory
result18.
Complementary surgeries, such as mammoplasty, brachioplasty, cruroplasty,
flankplasty, and torsoplasty, in addition to liposuction, are necessary to
improve body contour and obtain a satisfactory surgical result7,8.
This study included 13 ex-obese patients who underwent post-bariatric surgery. In
half of the patients, both the upper and lower levels were treated and, in the
other half, only the lower level. This study was composed of young men and
women, with a mean age of 44 years and a mean BMI of 26.15 kg/m², similar to
that found in literature1,19,20.
Complications were related to the patient’s general condition and the extent of
the procedure, which were classified into major and minor21 complications. In this study, the most prevalent
complications were wound dehiscence (mainly in the thighs) and seroma, and were
treated in an outpatient setting, with dressings, drainages, or punctures. There
was one case of pulmonary thromboembolism, which was treated with low molecular
weight heparin, without any complications.
Several authors have reported higher complication rates, especially for
torsoplasty or abdominoplasty, with a complication rate around 35%15,18,22,23. The
incidences of major and minor complications in this study were consistent with
literature15,18,22,23.
In this study, the mean surgery time for the lower level was 4 hours and 54
minutes and 4 hours and 5 minutes for the upper level. Baroudi defined as
surgical time limit as 360 minutes. Surgical procedures that exceed this time
limit are associated with post-operative complications24.
A reduction in the surgical time requires a high level of coordination of the
surgical team, since it allows multiple procedures to be performed
simultaneously by surgical teams working separately on different areas of the
body .
If the procedures on each body part were performed at separate times and by a
single team, the surgery would have lasted a total of 13 hours and 20 minutes
(abdominoplasty: 4 hours; mammoplasty: 3 hours and 20 minutes; brachioplasty: 3
hours; cruroplasty: 3 hours). Therefore, approximately 9 hours room hours were
saved (costs and security), in addition to a decrease in the patient’s isolation
period due to repeated surgeries.
The patients had a satisfaction level of 92.30% at the post-operative follow-up.
This percentage demonstrates a high degree of satisfaction, similar to data
found in literature when comparing similar techniques of post-bariatric plastic
surgery22. Similarly, we observed a
higher percentage of satisfaction in the patients who underwent the two-level
approach, similar to literature, which revealed that body contouring surgery
that addresses several segments of the body generated a higher satisfactory
surgical result due to body harmonization when seen in its totality7,8.
The analysis of the results by the external evaluator, 53.84% of the cases
presented a surgical result considered great, 38.46% good and 7.69% regular. No
results were scored as bad. Therefore, it revealed a rate of 92.30% of the cases
classified as good or great, demonstrating a high degree of approval of surgical
results.
CONCLUSION
In order to have a good functional and aesthetic result, a pre-established
routine and a systematic procedure and sequential steps are important.
Additionally, we emphasize the need for a well-trained and capable surgical team,
made up of several members, all following the same surgical technique, so that
the process can be optimized with a shortened surgical time, minimizing
consequent complications.
Satisfactory results obtained with low complication rates, minimal patient
absence from normal life, better aesthetic results, and much lower costs proves
the applicability of the routine of Plastic Surgery at Daher Hospital in
post-bariatric patients.
COLLABORATIONS
|
JCD
|
Analysis and/or data interpretation, final manuscript approval,
realization of operations and/or trials.
|
|
ACC
|
Conception and design study, writing - original draft
preparation.
|
|
MCC
|
Analysis and/or data interpretation, realization of operations
and/or trials.
|
|
BEP
|
Analysis and/or data interpretation, realization of operations and/or
trials.
|
|
GCS
|
Conception and design study, writing - original draft
preparation.
|
|
LDPB
|
Conception and design study, writing - original draft preparation.
|
|
RCSD
|
Conception and design study, writing - original draft preparation.
|
|
LMCD
|
Conception and design study, writing - original draft
preparation.
|
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1. Hospital Daher Lago Sul, Brasília, DF,
Brazil.
Corresponding author: José Carlos Daher, Quadra 7,
SHIS QI 7 conjunto F, Lago Sul, Brasília, DF, Brazil. Zide Code: 71615-660.
E-mail: daher@hospitaldaher.com.br
Article received: April 02, 2018.
Article accepted: April 16, 2019.
Conflicts of interest: none.
