Introduction

“The World Health Organization (WHO) classifies obesity as a highly complex Chronic Noncommunicable Disease (NCD) and is considered a challenge of the 21st century, with global repercussions. According to the Atlas of the Food and Nutri-tional Situation in Brazil, published by the Ministry of Health in 2020, a survey involving 12,776,938 adults revealed that 63% of them are overweight. Obesity is a multifactorial condition, presenting a significant risk due to its comorbid-ities and psychosocial impacts that worsen with increased weight”.¹ The pursuit of a new body image often leads postbariatric patients to reconstructive plastic surgery. However, a large proportion of these patients do not fully understand what surgery can achieve and the potential results. Even after consultation and medical guidance, a significant percentage of patients perpetuate an idealized body image and, consequently, may be dissatisfied with the outcome.

In Civilization and Its Discontents, Freud defines sublima-tion as the defense mechanism that takes energy from something potentially harmful and transforms it into some-thing useful, modifying both the object and the goal.² This unconscious modification alleviates and protects the subject from psychic suffering, such as anxiety, frustration, and mental conflict.

“Preoperative assessment and preparation are essential for postbariatric patients, especially the psychological and social aspects permeating everything from the decision-making process to the entire recovery and adaptation to the new life. This stage includes assessments, guidance, clarification of realistic treatment expectations, and in-depth interviews regarding the subject’s relationship with food, their life history, and their relationship with their own body [...]. Managing expectations and idealizations regarding bariatric surgery through self-knowledge and awareness of the complexity of this process is key to a healthy adaptation.”³

Disorders existing during the period of obesity without adequate psychological support can reappear or trigger new conditions after bariatric surgery or body contouring.

The onset of new personality disorders or the worsening of preexisting conditions can result in weight regain that may be partial or very significant.

The article “Body Dysmorphic Disorder and the influence of the media in demand for plastic surgery: the importance of proper evaluation” cites Dr. Gustavo Costa Goulart, who highlighted that the perception of the body as one’s own seems natural and intuitive; however, in reality, it is not quite so: [...] “throughout life, the vision of the body will be marked not only by images but also by definitions (signifiers) and own sensations. So, we have a body that is apprehended by its imaginary aspect (appearing), by its symbolic aspect (being), and by its real aspect (body experience not imagined or symbolized by the subject and which emerges abruptly).”⁴

A patient seeking reconstructive plastic surgery after bariatric surgery may be feeling vulnerable, having low self-esteem, and often experiencing a profound existential void. Thus, they end up isolating themselves from society or trying to fit in by masking their feelings of failure, using humor, or even playing the victim to get attention from their peers.

It is the psychologist’s role to identify and treat psycho-logical changes that may hinder the process, guiding the patient from bariatric surgery to reconstructive plastic sur-gery, and preparing them for the profound bodily, social, and sexual changes that may occur in their life.

Objective

The current study aimed to specify and manage the real and imagined expectations of postbariatric patients undergoing reconstructive plastic surgery procedures with support from a multidisciplinary team. The study also aimed to evaluate and identify potential disorders, risks, and the level of psychological preparedness of these patients for such surgi-cal treatments.

Materials and Methods

The present study comprised 203 postbariatric patients of both genders (164 women and 39 men) who underwent reconstructive plastic surgery with 4 different teams of plastic surgeons at Hospital Ruben Berta, in the city of São Paulo, Brazil (►Fig. 1)

Fig. 1 - Total number of patients per gender.

Fig. 1 - Total number of patients per gender.

All participants agreed to undergo unpaid consultations and preand postoperative testing for reconstructive plastic surgery with the same psychologist, as well as personality testing, including the Revised Neuroticism, Extraversion, and Openness Five-Factor Inventory (NEO) Five-Factor Inventory (NEO FFI-R) and a preoperative psychological assessment questionnaire for postbariatric plastic surgery. All patients signed an informed consent form for psychological treat-ment, ensuring compliance with the ethical criteria and requirements of the research.

Results

We analyzed the results of the NEO-FFI-R and questionnaires to identify consistencies in each subject’s characteristics, assuming that human attributes are stable, steady features that, combined, form a personality.⁵

Of the 203 patients monitored, 162 (136 women and 28 men) presented some mental disorder. None of the identified disorders led to the suspension of postbariatric plastic surgery (►Fig. 2).

Fig. 2 - Number of patients and diagnosed disorders.

Fig. 2 - Number of patients and diagnosed disorders.

Among the 136 women with some mental condition, we identified body dysmorphic disorder (n ¼ 49 patients), so-matic symptom disorder (n ¼ 23 patients), bulimia nervosa (n ¼ 17 patients), orthorexia (n ¼ 13 patients), mood disor-der (n ¼ 13 patients), anorexia nervosa (n ¼ 10 patients), muscle dysmorphia (n ¼ 6 patients), and alcohol-related disorder (n ¼ 5 patients) (►Fig. 3).

Fig. 3 - Personality disorders diagnosed in female patients.

Fig. 3 - Personality disorders diagnosed in female patients.

Regarding the 28 male patients with some mental condi-tion, we identified muscle dysmorphia (n ¼ 12 patients), alcohol-related disorder (n ¼ 6 patients), body dysmorphic disorder (n ¼ 3 patients), mood disorder (n ¼ 3 patients), orthorexia (n ¼ 2 patients), and somatic symptom disorder (n ¼ 2 patients). No male patients presented with bulimia nervosa or anorexia nervosa (►Fig. 4).

Fig. 4 - Personality disorders diagnosed in male patients.

Fig. 4 - Personality disorders diagnosed in male patients.

Discussion

The current study evaluated the preand postoperative motivations and expectations of patients, their psychological state, and the existence of any psychological disorders that would contraindicate reconstructive plastic surgery after bariatric surgery. Our analysis encompassed personality disorders, anxiety disorders, obsessive-compulsive disorders (OCDs), somatic symptoms, and, in particular, eating disor-ders, which we believe to be the most common in postbari-atric patients.

We observed that most patients underwent preoperative psychological evaluation for bariatric surgery, but with no follow-up. This discontinuity leads many patients to seek reconstructive plastic surgery with the same preexisting disorders, or even with worsening of their psychopathologi-cal condition. This situation undermines the procedure’s effectiveness and can negatively impact the doctor-patient relationship, possibly leading to legal action.

Our results indicate that ongoing psychological support is crucial for postbariatric patients; however, it did not occur in most cases herein analyzed. This support is essen-tial for body-image readjustment, development of a new identity after weight loss, and management of the signifi-cant changes that will occur in the patient’s life, regardless of the presence of preexisting psychological disorders. Such need reinforces the importance of a humanized multidisci-plinary team with psychological support throughout the entire surgical process, from the preoperative period to body remodeling.

Continuous, collaborative interaction with the psycholo-gist can enhance the patient’s well-being. This relationship provides a broader, more effective approach, which encom-passes surgical outcomes and physical, psychological, and emotional aspects. Providing psychological support before and after surgery helps manage patients’ anxieties and expectations, leading to a healthier, more balanced recovery. The involvement of a psychologist in this journey promotes an integrated intervention, enhancing the physical benefits of surgery and contributing to the patient’s emotional sta-bility and mental health. This integrated intervention enhan-ces satisfaction for the patients and the surgical team, fostering collaboration among the several healthcare pro-fessionals involved in the treatment.

Conclusion

Adopting a multidisciplinary approach from the initial deci-sion to undergo bariatric surgery through the postoperative period of bariatric and reconstructive plastic surgeries is key to the success of the treatment. The inclusion of regular psychological consultations in this process is essential to help the patient adapt to the physical and emotional changes resulting from the surgeries, promoting not only an im-proved quality of life but also more effective integration between the clinical and surgical teams.

This holistic approach maximizes therapeutic and surgi-cal outcomes, it has a positive impact on the patient’s overall well-being, it benefits all professionals involved, and it ensures more comprehensive, humane treatment, and pa-tient satisfaction with the results.