Body shaping

Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

Overview
Body contouring is a general term that refers to any surgical procedure that alters different areas of the body, whether it is in a massive weight loss patient or not. Body contouring after massive weight loss refers to a series of procedures that eliminate and/or reduce excess skin and fat that remains after obese individuals lose a significant amount of weight, in a variety of places including the torso, upper arms, chest, and thighs.

History
Obesity is in epidemic proportions in the US and many parts of the world. It is defined as a condition where a person’s Body Mass Index (BMI) reaches 30 or more. BMI is calculated by dividing the patient's weight in kilograms by their height in meters, squared. Normal weight individuals have a BMI that ranges from 18 to 25. Overweight people have a BMI from 26 to 30, with 30 and above people considered obese. Once the BMI reaches 35 and above, patients are considered morbidly obese. From a BMI of 30 and above a person's life span is shortened. In addition, obesity negatively affects the economic health of a society as well as other aspects of adult and child health, often for life. Childhood obesity is on the rise in Europe as well.

Bariatric surgery
In response to a serious obesity crisis, medical science has devised a handful of bariatric (obesity treatment) surgeries, including gastric bypass, stomach stapling, lap banding, stomach reduction and other techniques that reduce the amount of food the stomach can hold. For instance, in the United States, the American Society of Bariatric Surgery (ASBS) reports that the year 2000 saw an estimated 37,700 surgeries to restrict the size of a patient’s stomach. But in 2006, the most recent year for which statistics are available, there were 177,600 such operations. Usually, by 18 months after the surgery, patients report having lost anywhere from 45 to 136 kg (100 to 300 pounds).

Body lifting
Food-restriction operations to the stomach have several side effects. One such undesirable side effect that is very bothersome and visible is the loose, hanging skin that covers much of a weight loss patient's body. Because hundreds of pounds have stretched the patient’s skin to the maximum, it has lost its elasticity and the ability to spring back. Instead, the newly slimmed patient must deal with so much extra hanging skin, he or she can actually stumble on an overhanging panniculus, the large apron of skin hanging from the stomach that can cover the pubis and groin areas. Notably, many extra inches (and sometimes, feet) of floppy skin hang from the upper arms, the chest, the stomach, the upper thighs and buttocks.

Most people who have lost massive amounts of weight complain about the difficulty of getting their fleshy arms into sleeves and their excess stomach skin tucked into clothing. Many say that sitting on the loose skin is like sitting on Jell-O. Most women in this state condition require a mastopexy, or breast lift, often in conjunction with breast implants. Men who have body shaping surgery usually undergo male breast reduction surgery to remove the pendulous skin hanging from their chests.

The extra rolls and sheets of skin rub against each other, creating many spots of irritation and leading to hygienic difficulties. The masses of excess skin also make any form of exercise difficult. Many patients become reclusive and are hesitant to enter romantic or social relationships. Said one massive weight loss patient: "After I lost 155 pounds, (70 kg) it was like I had a size 26 skin hanging on my size 8 body".

While the procedure is expensive, often running in the neighborhood of US$20,000 to US$50,000 for an entire body, it usually leaves long, visible scars on the arms, chest, stomach and legs. Nonetheless, the body lifting procedure is growing in popularity, thanks to a concomitant rise in weight loss surgeries on the stomach. For instance, in the year 2000, 207 lower body lifts took place, according to the American Society for Aesthetic Plastic Surgery (ASAPS). But in 2006, 10,323 such lift operations took place, an increase of 19 percent over the previous year. Most surgeons break the surgical task into an upper, and a lower, body lift. A lower body lift removes the sagging skin on the back, abdomen, buttocks and thighs while the upper body procedure removes loose skin from the arms, breasts and chest.

Potential risks and side-effects
Body lifting is not lightly undertaken. The process requires a commitment on the part of the patient who must stay with the program through bariatric surgery, during the 18 months required for weight loss, then the body contouring procedures and recovery. Often, beginning to end takes three years. A single body lifting operation can require seven to 10 hours under general anesthesia, blood transfusions and often, another surgeon to assist. Plastic surgeons advise patients that body shaping is not an obesity operation. A patient who is more than 50 percent over his or her ideal weight must first drop as many pounds as possible before proceeding. Other medical considerations the plastic surgeon must take into account include scars already present on the body, current medical conditions like heart disease or bleeding disorders, and if the patient smokes. Other possible risks include infections and reactions and complications due to being under anesthesia for longer than six hours. The patient may also experience seroma, a build up of fluid; dehiscence (wound separation) and deep vein thrombosis (blood clots forming in the legs.) Rare complications include lymphatic injury and major wound dehiscence. The hospital stay for the procedure can require from one to four days while recovery can require about a month for a total body lift. Essentially, the patient trades "skin for scars". But skin relaxation is always a risk and may not be stopped with a single procedure. Reputable plastic surgeons will explain all the risks and complications in full to their patients and even encourage a second or third consultation visit with other plastic surgeons to get additional views on such a major undertaking.

Body lifting surgical procedures
While body shaping can be done in one marathon session, it is usually broken into one to three surgical stages, with the patient under general anesthesia. But if the patient is a smoker, has a history of deep venous thrombosis or clotting disorders along with a high BMI and other medical risk factors, the surgeon will probably insist on doing several short procedures in a hospital setting to insure maximum safety for the patient.

Please note that there are also non-surgical procedures such as the UltraShape procedure. It is safe, non-invasive and backed-up by extensive clinical trials.

The following are the individual components of body contouring:

Arm lift or brachioplasty. The extra flesh on the arms of bariatric patients virtually always appears on the underside of the upper arm and is sometimes referred to as "bat wings". Surgeons realize they must use long incisions made from the armpit to the elbow to remove the skin and create a more pleasing contour. Consequently, surgeons open the arm on its underside so that the resulting scar is fairly well hidden. A brachioplasty procedure can employ some liposuction after the incision is made. With the arm opened, the surgeon pulls the skin tight and then trims away the excess skin which, depending on the patient, can be a pound of skin per arm or more.

Breast lift or mastopexy. By trimming excess tissue from the upper breast, the surgeon can move breasts which usually droop to the umbilicus to a more upright and full position. The procedure also often requires an implant to make up for lost fat and tissue inside the breast. Scars on women are almost always hidden inside the area covered by the bra. Most men gladly exchange several light, quickly fading horizontal scars across their chest muscles for a sleeker upper trunk.

Stomach lift or abdominoplasty. Excess skin hanging down over the pubic region is often the distorting feature that most concerns and bothers patients. The stomach pannus retains moisture, and causes rashes due to skin rubbing against itself which usually leads to poor hygiene. While the surgical procedure to remove it is known as a panniculectomy, there is often more work to be done for patients who suffer from large amounts of hanging skin. To provide improved contours on the waist, back and flanks, surgeons sometimes perform a belt lipectomy, (also known as a torsoplasty or a circumferential lipectomy). The incision goes all the way around the patient’s midsection at the level of the lower waist. The surgeon uses more liposuction on the stomach and flanks while trimming excess skin from the patient’s back and sides as well. The abdominoplasty and belt lipectomy incisions are placed so that the resulting scar is hidden within most underwear and swimsuits.

Lower body lift trims excess skin on the buttocks and thighs. For an inner thigh lift, the surgeon makes an incision high on the inner leg, starting near the groin and continuing down to the knee. Some fat may be removed with liposuction. The surgeon then removes excess skin and redrapes the remaining skin before closing the long incision, leaving the patient with tighter and more attractive thighs.

The outer thigh and buttock can be lifted through a hip-to-hip incision across the back, above the buttocks.

Usual results
While considered major surgery, the outcome of body shaping is generally extremely satisfying to patients although it can require several months to see the full effects of the procedure. But with a flatter stomach, more curve to the waist and smaller hips, less "back fat" and smaller, better shaped buttocks, patients usually develop more self confidence and become more active. After healing, most patients can buy and fit into easily available clothing, participate in sports and physical fitness activities again and become more involved in social and romantic situations.

When researchers at the University of Pittsburgh enrolled 18 bariatric patients just before the subjects decided to undergo body contouring, their average age was 46, plus or minus ten years. The researchers studied the patients’ body perception, quality of life and mood at three and six months after the body contouring procedures. They found the subjects’ quality of life improved and significantly enhanced their moods which had remained stable at the six-month point. Most body lifting patients return to non-strenuous work in about two to three weeks.

Except for brachioplasty, virtually all body shaping procedures require the patient to wear a support or compression garment for two to six weeks. The garment speeds and aids in healing.

Patients can usually drive again within one to three weeks, depending on the extent of the surgery, their health and general robustness.