For many obese patients, bariatric surgery is only the first step in reinventing themselves. Once they've stabilized their body weights, many post-bariatric patients will undergo body contouring surgeries to help their skin fit their new bodies. Patients with size 28 skin sagging off of their suddenly size 8 bodies may need buttock lifts, upper arm lifts, lower body lifts, abdominoplasties, panniculectomies, breast lifts and breast reductions to remove the folds of excess, baggy skin - and to look as good as they feel.

Massive weight loss body contouring greatly differs from contouring procedures performed on normal-weight patients. Here's what I've learned in the 15 years I've been performing and teaching this growing discipline involving those surgical techniques that tighten and reshape loose body skin after gastric bypass surgery.

Counseling your patients
You might find it helpful to share these insights with your patients as part of your bariatric surgery program's pre-op seminars.

• Skin elasticity. Many post-bariatric surgery patients experience an extreme loss in skin elasticity, their tissue permanently damaged from being stretched to such an extreme and unable to maintain tightness or tone. Even though skin can be made to fit the body again through plastic surgery, these patients' skin will loosen much faster than patients with normal skin - although I've found that exercisers have better skin contraction.
• Multiple procedures. Massive weight loss patients should be aware that body contouring may require surgeons to address the entire body circumferentially and not just one or two specific areas, as is the case with body contouring in more normal-weight patients. Plastic surgeons must re-contour both the entire upper- and lower-body trunks after a patient has lost massive amounts of weight.
• Staged reconstruction. The body contouring process should occur in stages, typically every three months to six months. Although some patients opt to only remove the apron of skin hanging from the stomach, many undergo circumferential trunk lipectomy, a technique that involves removing excess skin from around the entire waistline, front and back. Yet other patients opt for a lower body lift which includes removing and lifting the skin up from the knees, almost like pulling up a pair of pants. In addition, some patients may wish to have excess skin removed from other areas, including their arms, backs and legs. As a general rule, six hours of surgery is enough at one time. I will have the patients prioritize the areas that bother them the most, and then we start there.
• Liposuction? For some patients, liposuction is used to reduce overall bulk before skin reduction surgery. One concern for both the surgeon and the anesthesiologist is that patients undergoing liposuction require a lot more tumescent fluids because their skin stretches so easily.
• Scarring. The body-shaping operation creates long scars down the arms, up the legs and across the lower stomach. It's important to map the excess tissue to be removed and to anticipate the movement of the skin left behind. This lets the plastic surgeon visualize where the scars will be after the tissue is removed and place them where they will be hidden by underwear or in a belt-like position. We hide the scars as well as possible, putting them under bikini and bra lines and on the insides of arms and legs about where the clothing seams would be.
• Patient selection. Post-bariatric surgery usually occurs one year after the procedure or when weight loss has plateaued for three months to six months. The best candidates are healthy individuals who've stabilized their body weight. After bariatric surgery, weight loss generally continues for about a year-and-a-half before stabilizing. People with co-existing conditions that aren't fully under control, such as diabetes or heart problems, may not be eligible for body contouring surgery.

• Insurance coverage. These surgeries aren't cheap. A total body lift in most parts of the nation, for example, averages about $30,000. Some insurance companies may cover part of the cost of body contouring surgery (such as in the documented case of overhanging skin causing rashes or fungal infections), but many payers consider these cases cosmetic and not reconstructive.
• Risks. There are risks associated with post-massive weight loss body contouring surgery that are not common with other types of body contouring. You should consider fluid shifts that occur after large amounts of skin and fat are removed. Post-operatively, keep in mind that seromas (particularly in the abdomen and back) occur frequently.
• Nutrient deficiency. Patients may be deficient in key nutrients as a by-product of their massive weight loss surgery - most often, iron, calcium and potassium. We check lab values on these patients at least a week before their surgeries. Checking early allows time to correct whatever deficiencies you find. Waiting until the day of surgery can put you in the position of canceling at the last minute, losing a large chunk of surgery time and disappointing the patient. It's important to consider what type of bariatric procedure the patient had - restrictive (Lap Band, for example) or malabsorptive (Roux-en-Y, for example). I'll do a full metabolic workup on patients who've had a malabsorptive procedure before we go ahead with the surgery.
• Hematoma. In any extensive abdominoplasty, hematoma is a risk. After experiencing a couple of hematomas, I began to administer 10mg of vitamin K subcutaneously before surgery. Vitamin K is a fat-soluble vitamin and its absorption may be decreased in massive weight loss body contouring patients, especially those who've had the absorptive limb of their small bowel shortened.
• Losing the umbilicus. Many post-op open bariatric surgery patients may have a large incisional hernia and repair of this may involve the umbilicus. We warn patients of the risk of losing the umbilicus during the hernia repair if the hernia involves the umbilicus and the hernia repair is combined with an abdominoplasty.
• Adhesives and sutures. For comfort's sake, I use topical skin adhesive (Dermabond) to close rather than sutures or skin-strips. Many patients are allergic to adhesive, and with Dermabond, I can avoid the use of much tape. Also, particularly in thigh lifts, I have seen a reduction in infections since I started using Dermabond.
• Patient warming. It's not unusual that you'll have to prep these patients from head to toe. To avoid the patients' getting cold, I keep the OR warm (70?F to 72?F), use forced-air warmers (sterile ones are available for use during the case) and warm the prep sets during prepping.
• Pulmonary embolism. To limit the risk of pulmonary embolism, I use heparin post-operatively, as well as early ambulation and leg squeezes. Patients may be resistant to movement because of pain. A pain pump (such as the On-Q system) in addition to a PCA usually helps.
• Seroma. No one, to my knowledge, has figured out a way to prevent seroma all together. I use four Blake Silicone Drains to fully drain the large space in the abdomen and only start to remove them when the drainage is less than 40cc in a 24-hour period.

Facelifts for figures
More than 52,000 body-contouring procedures were performed for massive weight loss patients in 2003, according to the American Society of Plastic Surgery, which expects body contouring procedures for post-bariatric patients to have grown by about one-third in 2004.

With the growing popularity of gastric bypass surgery to treat morbid obesity, body contouring after massive weight loss has become a focus of the plastic surgery community. It's critical to understand and appreciate how it differs from standard body contouring techniques. As you can see, you can prepare your patients for what lies ahead by educating them about body contouring before their surgery.