2.2 Obesity
2.2.8 Benefits of plastic surgery
The basic principle of body contouring after massive weight loss is to remove excess skin and tighten the cutaneous tissue to the new body volume and reach a harmonious silhouette. It could therefore eliminate physical or psychological handicap bound to the excess skin. It is thus essentially a functional surgery. According to the American Society of Plastic Surgeons, body contouring procedures concerned 52,603 patients in the USA in 2010.
Body contouring is proposed to patients who reached a stable weight after a massive weight loss, usually at least 12-18 months after bariatric surgery. According to the status and the request of the patient these interventions are mainly made at the abdominal level (abdominoplasty) and breasts (mammoplasty) but also in inner thighs (cruroplasty) or arms (brachioplasty). These interventions are not free of complications, and they create scars which, in certain cases, can be disappointing for the patients. Therefore patients have to be informed about these sequels, even before to undergo bariatric surgery. In collaboration with our
“bariatric” multidisciplinary team, we participate actively in preparation programs of patient who will undergo bariatric surgery in our center. We inform them about the skin excess that could appear after bariatric surgery, and its possible treatment by body contouring. Seen the risks and scars, the patients so wonder it's worth it?
2.2.8.1 Effects of body-contouring on quality of life (Paper 1)
In a prospective study we demonstrated that plastic surgery improves significantly HRQoL after RYGBP. 98 consecutive patients who had body contouring after gastric bypass for obesity were included, and with a mean follow-up of 7.5 years their HRQoL was compared to their situation before body controuing and to a matched control group containing 102 patients who had only RYGBP. Of the patients who had body contouring, 57 % evaluated their HRQoL “much better” in comparison to only 22 % of patients without body contouring (p<0.001).
The improvement was significant in all sub-items of HRQoL: self-esteem, social life, work ability, sexual activity and physical activity (p<0.001), and remained stable over time.80 (Annexes. Paper 1) This HRQoL improvement by plastic surgery has been confirmed later by other authors. 76,84-86 2.2.8.2 Benefits of body-contouring on weight loss stability (Paper 2)
Even RYGBP offers a fast and massive weight loss within the first 18 months after surgery, as many as 50 percent of patients may unfortunately regain some of the lost weight. The mean weight regain within the first 18 to 36 months after surgery is 5 to 10 percent and it becomes 10 to 15 percent over the course of the next 10 years.87 This weight regain can be associated with a recurrence of comorbidities, such as hypertension, diabetes, and hyperuricemia. 87-89 Kalarchian et al. concluded that any interventions that improved the psychosocial functioning of a patient would also strengthen the weight loss maintenance. 90 Considering that body contouring improves HRQoL weight loss, we were interested to assess the effect of body contouring on weight loss and stability after RYGBP.
In a prospective match-control study, we intended to evaluate the benefit of plastic surgery on body weight control after RYGBP. By comparing 98 patients who underwent body-contouring after RYGBP, to 102 matched patient without body-contouring, we demonstrated that plastic surgery improves significantly weight loss stability.91 RYGBP alone resulted in an initial massive mean weight loss of 45.2 kg. Then, the patients reached a plateau approximately 12 to 18 months after surgery, thereby allowing them to obtain a minimal mean weight of 78.3 kg (range, 65 to 92 kg) and a mean BMI of 29.9 kg/m2 (range, 26 to 34 kg/m2) (p < 0.001). Beyond the second year after RYGBP, patients without body-contouring started to regain significant more weight than those with body-contouring (1.78 kg/year vs versus 0.51 kg/year, p = 0.001).
The differences between groups gradually became more significant over time: from the minimum weight achieved by RYGBP, the mean weight regain at 7 years was only 4.8 kg for patients with body-contouring and 20.1 kg for those without (p< 0.001). This resulted in a higher final weight for patients with RYGBP alone as compared with those who had body-contouring (101.2kg/ BMI= 37.2 versus 82.5 kg/BMI=30.6 kg/m2 respectively; p = 0.01).91 (Annexe. Paper 2)
As hypothesized in the beginning, this weight improvement by plastic surgery could be explained by improved HRQoL that these procedures offer. However, the reduction of fat and skin during contouring could also participate to this weight stability. During the body-contouring procedure, a mean mass of 2.04 kg (range, 0.45 to 6.3 kg) of adipose tissue was excised from patients included in our study. Most of these tissues were from the abdominal part, the most resistance adipose tissue.
As demonstrated before, it is known that physiologically adipose tissue show some resistance to lose volume and the fat mass is spontaneously maintained stable. (Sect. 2.2.2) This phenomenon is due to the fact that the weight loss, even massive is linked to a reduction in the size of adipocytes and not in the number of cells. As mature adipocytes do not return to the precursor stage; and hyperplasia seems not or lightly reversible10,49,50, hypotrophic adipose tissue maintains its high capacity to store triglyceride again. This adipose tissue resistance could explain partially the difficulty of obese patients who underwent a massive weight loss, to keep stable their weight over time. Fat tissue discarding by body contouring could explain partially why patients who underwent plastic surgery gained less weight, in comparison to those how had still an adipose-cutaneous excess.
Moreover, obesity creates a local micro-environment in adipose tissue that promotes inflammation and fibrosis. This inflammatory condition could play a role in metabolic complications and cardiovascular disease. As described before (Sect. 2.2.1) weight loss is associated with a decrease fibrosis, but the pathological excess fibrosis created by obesity is not completely resorbed and may alter the remodeling of adipose tissue and limiting the fat loss.58 Body-contouring surgery by reducing a part of this residual “pro-inflammatory and fibrotic adipose tissue” could contribute to weight stability and maybe to reduce metabolic diseases. In
a meta-analysis performed by Boriani et al., and a review by Esposito et al., it has been demonstrated that adipose tissue mass reduction even by liposuction alone, could reduce adipokines and improve metabolic disease, particularly insulin resistance. 37,92
In resume, we concluded that plastic surgery plays an important role in treatment of patients after massive weight loss. We demonstrated that body contouring, despite important scars, significantly improves satisfaction, HRQoL and weight of patients after gastric bypass. Therefore, the treatment of morbid obesity should not be deemed achieved unless plastic surgery has been considered. Data of our clinical studies have to be used as an argument in favor of cost coverage of body contouring by health insurances. These procedures should be considered as a reconstructive surgery of obesity and the treatment of its sequela.