The proliferation of bariatric surgery procedures performed each year in the United States has led to a burgeoning demand for body contouring, a subspecialty of plastic surgery designed to help patients improve their cosmetic appearance.

Prior to 2000, it was rare for patients who experienced massive weight loss to seek help from plastic surgeons; in fact, this patient population was almost nonexistent, according to Dr. Al Aly, a board-certified plastic surgeon who practices in Iowa City, Iowa.

Today, the demand for procedures such as abdominoplasties, upper arm lifts, and thigh lifts has never been higher. According to the American Society of Plastic Surgeons, between 1992 and 2008 the number of abdominoplasties performed grew by 593%, from 16,810 to 116,512; the number of thigh lifts grew by 731%, from 1,023 to 8,504; and the number of upper arm lifts grew an astounding 2,982%, from 434 to 13,374. Meanwhile, the number of lower body lifts––a procedure that essentially did not exist in 1992—stood at 8,647 in 2008.

Dr. J. Peter Rubin, a board-certified plastic surgeon who directs the multidisciplinary Life After Weight Loss clinical program at the University of Pittsburgh, estimates that 90% of his clinical practice involves body contouring after massive weight loss. “These are fairly complex and technically challenging procedures that are best done by surgeons who have a strong grounding in plastic surgery principles and strong training in plastic surgery,” said Dr. Rubin, coauthor of “Aesthetic Surgery After Massive Weight Loss” (Elsevier Medical Publishing, 2006).

Dr. Aly evaluates potential body-contouring candidates a minimum of 18 months after they have undergone bariatric surgery. “We tend to not want to operate on people who are aiming for specific weight levels,” said Dr. Aly, author of “Body Contouring After Massive Weight Loss” (Quality Medical Publishing, 2005). “We want to operate on people who are in a comfortable lifestyle and are not doing heroic things to reach a particular weight level. If you have access to the bariatric surgeon that the patient was referred from, that's one of your best sources. Ask them if they feel that the patient has stabilized their weight loss.”

Dr. Susan Downey, a board-certified plastic surgeon who practices in Los Angeles, addresses goals and expectations with body-contouring candidates up front. She asks them about their cosmetic priorities, how long they've been at their present weight, and whether they've had plateaus with their weight loss. In her practice, abdominoplasty usually tops the list of procedures requested, followed by breast lift/augmentation; arm lift; thigh lift; and lower body lift (belt lipectomy), a combination procedure that includes abdominoplasty, a thigh lift, and a buttock lift.

“What bothers me [from a cosmetic standpoint] may not be what bothers them,” Dr. Downey noted. “I had one patient who wanted her eyes done first because the bags under her eyes got more pronounced as her face got smaller from the weight loss. You can do two or three procedures if a patient is in good medical condition. We usually limit ourselves to about 6–8 hours of surgery.”

According to published reports, Dr. Downey said, up to 30% of patients with massive weight loss have complications after body contouring. “I would say it's up to 10% for a major complication and up to 30% for a minor complication,” she estimated. “These patients have a higher rate of hematoma formation, a higher rate of seroma, and wound-healing issues. A lot of it has to do with the fact that the skin is so overstretched at the time that you do the surgery.”

Extensive scarring after the procedures is common, “but the improvement in body contour is quite dramatic and well worth the scars,” she added.

Recovery time varies among patients, Dr. Aly said, and tends to be longer after a belt lipectomy (4–6 weeks) than after other common procedures, including an upper body lift (2–3 weeks), an upper arm lift (2–3 weeks), and a thigh lift (2–4 weeks).

Some medical insurance companies cover the panniculectomy portion of the abdominal contour, including anesthesia, but other procedures generally are not covered. “That's one of the issues with this field: The insurance companies are bound to the criteria of medical necessity,” Dr. Rubin said. “It's sometimes hard to justify true medical necessity by the standard of the insurance company for some of these body-contouring operations, despite the overwhelmingly positive impact it will have on the person's quality of life. With these economic times, I'm not sure we're going to see that getting better quickly.”

These procedures produce an immeasurable impact on patient self-perception, Dr. Aly stated, recalling that a patient with massive weight loss once told him, “[Bariatric surgery] gave me back my life. It's part of a life transformation. Plastic surgery allows me to enjoy it.”

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Before and after results of an upper body lift in a male bariatric surgery patient are shown.

Source COURTESY DR. AL ALY

Demand Soars for Postbariatric Cosmetic Fixes