Review Article Amy S. Colwell, MD; and Loren J. Borud, MD METHODS RESULTS

Transcription

1 Review Article Optimization of Patient Safety in Postbariatric Body Contouring: A Current Review Amy S. Colwell, MD; and Loren J. Borud, MD Postbariatric body contouring is a major growth field in plastic surgery as a direct result of the increasing incidence of bariatric surgery performed in the United States. As experience has accumulated in this subspecialty, technical procedures have been refined and dramatic aesthetic benefits have been seen in postoperative results. However, few objective guidelines exist on the optimization of patient care and safety in this complex patient population. This study sought to review the literature on body contouring after massive weight loss and patient safety to provide the reader with a summary of current recommendations. A literature review was performed with PubMed and MEDLINE. Eighty relevant articles, ranging from case reports and expert opinions to prospective randomized trials, were identified and reviewed in detail. Literature consensus guidelines included completion and stabilization of weight loss before surgery with a body mass index ideally less than 32, smoking cessation, nutritional assessment, anemia screening, usage of mechanical prophylaxis against thromboembolism, and strong consideration for usage of chemoprophylaxis with low molecular weight or unfractionated heparin. Procedures should be performed in accredited facilities with appropriately trained staff, and special intraoperative consideration should be given to patient positioning and avoidance of hypothermia. Postoperative management is optimized by the development of clinical pathways involving the surgeon, patient, and support staff. (Aesthetic Surg J 2008;28: ) Obesity is a worldwide health problem and the second leading cause of preventable death in the United States. 1 The health consequences of obesity manifest in an increased incidence of diabetes, coronary artery disease, hypertension, osteoarthritis, obstructive sleep apnea, deep venous thrombosis (DVT), and postoperative complications. The advent of bariatric surgery has provided a means of large, rapid, and sustained weight reduction to bring patients closer to their ideal body weight. The dramatic rise in the number of gastric bypass procedures has been paralleled by a similar increase in body contouring procedures to bring patients closer to their ideal body shape. Although postbariatric body contouring procedures are associated with high rates of patient satisfaction, postoperative complications continue to negatively impact initially satisfying results The massive weight loss (MWL) patient may be at increased risk for these complications secondary to potential nutritional deficiencies, persistent obesity, venous varicosities, and poor quality, inelastic tissue. 14,15 In an attempt to minimize Dr. Colwell is from the Division of Plastic Surgery, Massachusetts General Hospital, Boston, MA. Dr. Borud is from the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. complications and provide an optimal outcome following postbariatric body contouring, we have reviewed the literature on body contouring after MWL and on patient safety issues in this population. We summarize our findings and indicate where future research may be directed. METHODS A literature review was performed using the PubMed and MEDLINE databases for articles published on body contouring in the MWL patient and on patient safety issues that need special attention in the MWL patient, such as DVT prevention, prevention of intraoperative hypothermia, and operative positioning. In addition, 2 textbooks specifically focusing on body contouring after MWL were reviewed. RESULTS A total of 80 relevant articles, ranging from case reports and expert opinions to prospective randomized trails, were identified and reviewed in detail. Case reports with fewer than five patients and letters to the editor were omitted from analysis. In addition to the literature articles, information on patient safety from the two body contouring textbooks was incorporated into the review. The results are summarized in three Aesthetic Surgery Journal Volume 28 Number 4 July/August

2 sections: preoperative, intraoperative, and postoperative considerations. Preoperative Considerations Timing of surgery and staging. Body contouring surgery should only be considered after the patient has achieved a stable weight plateau for 3 months or longer. 16 Following bariatric surgery, weight loss typically decreases exponentially and then subsequently stabilizes after a period of 15 to18 months. It is advisable to consult with the patient s bariatric surgeon to help determine when the plateau has been reached. 17 The staging of multiple procedures is determined by both surgeon preference and the health of the patient. 18 A review of the literature found a paucity of articles that relate the number of procedures performed or operative time to rate of complications. In their series of 126 panniculectomies, Arthurs et al. 3 did not find operative duration an independent predictor of complications using multivariate logistic regression. Similarly, in an outcomes analysis of complications following body contouring surgery, Shermak et al. 11 found that combining 3 or more procedures in one operative setting was associated with an increased length of stay greater than 2 days, but there was no increased risk of wound dehiscence, seroma, or blood transfusion. Single-stage total body lift procedures offer many advantages for patients by decreasing cost, facilitating time off work, and decreasing the number of general anesthesia inductions. These procedures can safely be performed in healthy patients by a plastic surgeon and team experienced in body contouring surgery at a tertiary academic medical center as Hurwitz 16 has described at the University of Pittsburgh. There are no specific literature-based recommendations for surgeons with less experience, fewer assistants, or those who choose to perform outpatient procedures; however, a roundtable panel of body contouring surgeons recommended limiting surgery in one setting to 6 to 7 hours and waiting 3 months between staged procedures. 19 No objective data in support of this limitation have yet been published. Risk stratification. Major body contouring surgery can involve prolonged operative times, substantial blood loss and fluid shifts, and greater physiologic stress than even the bariatric procedure. Therefore, a thorough preoperative evaluation needs to address the American Society of Anesthesiologists (ASA) classification, nicotine use, maximum and current body mass index (BMI), history of DVT or pulmonary embolism (PE), nutritional status, and psychosocial health. ASA. The ASA serves as an imprecise guide to clinical health of the patient and predictor of anesthetic and surgical patient risks. Rohrich et al. 10 suggested that central body lifts be limited to patients with ASA grades of 1 (healthy) or 2 (mild systemic disease). Nicotine. Major body contouring surgery involves the creation of large tissue flaps. Nicotine causes vasoconstriction, which can result in flap necrosis, infection, and major wound healing complications. Body contouring procedures should proceed with great caution in nicotine users. 20 Most surgeons consider nicotine use a relative or absolute contraindication to body contouring, and urine cotinine tests can be used to ensure cessation of smoking at the time of surgery. BMI. BMI at the time of body contouring surgery is a predictor of aesthetic outcome and complication profile. Although there is no consensus on BMI criteria for this surgery, most authors advise against body contouring in patients with a BMI greater than 32 and recommend functional panniculectomy only for those with a BMI greater than 35. 3,9,11 In one series, patients with a higher maximum BMI had significantly greater complications than those with a lower maximum BMI. 9 The same series reported greater complications in patients with larger changes in BMI following MWL and a trend toward more complications with a higher BMI at the time of surgery. Complication risk and in particular risk of DVT increases significantly with increasing BMI and risks of surgery need to be weighed against functional benefit in obese (BMI 30) and severely obese (BMI 40) individuals. 3,12 Nutrition. MWL patients may become noncompliant with the postbariatric nutritional program. Protein malnourishment can negatively impact wound healing and particular attention should be focused on vitamins with known malabsorption following bariatric surgery including thiamine, vitamin D, calcium, iron, vitamin B 12, and folate. 14,15 Although routine laboratory screening for vitamin deficiencies is not mandatory and probably not cost effective, most authors have recommended a preoperative laboratory work-up, including a complete blood count, electrolytes, albumin, and prealbumin. 19 Anemia. Clinically significant anemia is known to occur following gastric bypass and is associated with decreased levels of iron and vitamin B ,22 Significant blood loss can occur during body contouring procedures and worsen an existing anemia, especially when multiple procedures are combined in one setting. Preoperative autologous blood donation has been utilized in hip arthroplasty and in pediatric surgery, and it may have value in selected patients undergoing body contouring. 23,24 Thromboembolism Prevention Venous thromboembolism is an important source of morbidity and the most common cause of mortality following body contouring procedures. 12 It is necessary to start thinking about thromboembolism prevention preoperatively and to continue well into the postoperative setting. The risk of DVT is highest in the first 1 to 2 weeks following surgery. Most MWL patients are classified as high risk according to criteria defined by the American College of Chest Physicians (ACCP). 25 This is secondary to ACCP-identified specific risk factors of major surgery, age older than 40 years, immobility, obesity (BMI 30), varicose veins, and estrogen usage. 438 Volume 28 Number 4 July/August 2008 Aesthetic Surgery Journal

3 Table 1. Venous thromboembolism prevention strategies amongst plastic surgery case series No. of Incidence patients Contouring Prophylactic bleeding/ Incidence Incidence Incidence in series procedure regimen hematoma of DVT of PE of seroma Aly 2 32 Belt lipectomy Early ambulation, SCD 3% 9% 37.5% Borud 5 64 Modified vertical Early ambulation, SCD 5% abdominoplasty Colwell 6 18 Autologous gluteal Early ambulation, SCD 5% augmentation, lower body lift Nemerofsky Lower body lift Early ambulation, SCD 3% 2% 1% 16.5% Rohrich Central body lift Early ambulation, SCD, LMWH 1% 0.6% 22% 1 hour pre-op and twice daily post-op until discharge Shermak Contouring of Early ambulation, SCD, 2% 2% 1% 13% abdomen/combined unfractionated heparin twice procedures daily post-op until discharge Strauch Mid-body lift Early ambulation, SCD, LMWH 1.4% 4 hours after surgery and then once daily until discharge DVT, Deep venous thrombosis; LMWH, low molecular weight heparin; PE, pulmonary embolism; SCD, sequential compression device. ACCP guidelines for high-risk general surgical patients include chemoprophylaxis with low-dose unfractionated heparin (LDUH) 3 times per day or low molecular weight heparin (LMWH) once daily. 25 If multiple risk factors are present, chemoprophylaxis is combined with mechanical prophylaxis using intermittent compression devices or graded compression stockings. However, there is no consensus statement or specific recommendations for patients undergoing body contouring procedures. For our patient population, the risk of venous thromboembolism has to be weighed against the relatively high risk of postoperative bleeding. In this setting, the use of mechanical prophylaxis is routine and intermittent pneumatic compression, graded compression stockings, or foot pumps should be functional before the induction of anesthesia. 26,27 These devices typically remain in place until the patient is fully ambulatory in the postoperative period. More controversial, however, is the usage and timing of chemoprophylaxis. Amongst the plastic surgery articles which detail patient DVT prophylaxis, varying regimens have been proposed (Table 1). 2,5,6,9,10,12,13 It should be noted that series with no complications contain considerably fewer patients than those with complications. In our own experience, mechanical prophylaxis was used as the sole method of prophylaxis and no clinically detectable venous thromboembolism was observed. However, 2 recent thrombotic events in our patients have served as a nidus to re-evaluate current protocols. Patient Safety in Postbariatric Body Contouring Several retrospective plastic surgery reviews and data obtained from experience in other high risk surgical specialties, such as orthopedics and colorectal surgery, support the use of chemoprophylaxis in body contouring procedures. 12,25,28 The current guidelines for prophylaxis after hip replacement include LMWH, which can be started 12 to 24 hours after surgery or 4 to 6 hours after surgery using half the usual dose. 29 Higher bleeding rates have been observed if LMWH is given less than 4 hours after surgery. Preoperative administration of chemoprophylaxis does not provide improved efficacy when compared to postoperative dosing when given within 6 to 12 hours of surgery, and preoperative prophylaxis given within 2 hours of surgery has been associated with an increased risk of bleeding. 29 LDUH and LMWH have been shown to have similar efficacy and bleeding rates. 25 LMWH has the advantage of once daily dosing and decreased heparin induced thrombocytopenia; however, it is more costly. Intraoperative Considerations Facility and staff. Any proposed body contouring surgery should be performed in a fully-accredited inpatient or outpatient facility. An appropriately trained anesthesiologist or nurse anesthetist is necessary to manage the complex physiology associated with these major procedures. Surgeons should be appropriately trained in plastic surgery and should tailor the operative plan according to the number of assistants available and the general status of the patient. Volume 28 Number 4 July/August

4 Figure. Intraoperative prone position in 15 reverse Trendelenberg. Intraocular pressure increases with prone positioning, and this increased pressure has been responsible for vision loss in rare cases. Positioning the patient in 15 reverse Trendelenberg, as emphasized by the black line, works to lower the intraocular pressure back toward baseline. Epidural anesthesia. If epidural anesthesia is to be used in the perioperative setting, special caution should be exercised during placement and removal if chemoprophylaxis for venous thromboembolism is concurrently being used. ACCP guidelines recommend timing for catheter placement and removal to avoid peak levels of heparin. 25 Hypothermia. Major body contouring surgery often requires lengthy operative times and an exposure of large surface areas of the body. Various techniques have been promoted to minimize hypothermia in surgical patients Forced-air heating blankets are recommended for all patients. When repositioning or moving from one anatomic region to another, heating blankets should be replaced or repositioned to cover as much of the patient as possible. Preoperative warming with forced-air heating should be strongly considered for lengthy cases. This has been shown to decrease the core temperature drop seen with anesthesia induction, and these effects in raising the core temperature are maintained hours into the surgery. Alternative or adjunctive means of warming the patient include increasing the temperature in the operating room and warming infiltration/intravenous fluid. 19 Patient positioning. Adequate personnel must be available and great care must be taken to reposition the patient appropriately throughout their surgery. 16,33 The cervical spine is maintained at neutral, and pressure points on the elbows, shoulders, hips, and lateral legs are appropriately padded to avoid compression injuries. Prone positioning is often required and presents special challenges in patient safety. Care must be taken to avoid endotracheal tube dislodgement or malposition during turning, and direct pressure on the nipples and male genitals are avoided. While standard ocular lubrication and taping of the eyes can prevent ocular damage in the supine position, the prone position results in an increase in intraocular pressure that has been responsible for vision loss in rare case reports The intraocular pressure increase can be mitigated by maintaining a reverse Trendelenberg position of 15 degrees while the patient is prone (Figure). Prevention of infection. According to standard operative guidelines, intravenous antibiotics are infused 30 minutes before the start of the surgical procedure. 37 Although there are no conclusive data to support prolonged administration of antibiotics for this surgical procedure, it is common practice to keep patients on a first-generation cephalosporin until their drains have been removed. Prevention of seroma. Seroma is the most common complication of surgery in many clinical series. 2,8,10 In order to decrease the rate of seroma, most authors place and maintain drains until output is less than 30 ml per day. Newer techniques of progressive tension sutures, fibrin sealant, and preservation of a thin layer of fat may help to reduce the incidence of seroma; however, little data currently support any one technique. 38,39 Postoperative Considerations The development of clinical pathways involving the surgeon, patient, and support staff have been shown to decrease patient morbidity and length of stay in multiple surgical series In addition, pathways serve to provide uniform care and manage patient expectations. In our protocol, patients are expected to ambulate with Table 2. Consensus guidelines Weight loss should be complete and stable before body contouring surgery Smoking cessation is strongly recommended before body contouring, and nicotine usage may be considered a contraindication to surgery Mechanical venous thromboembolism prevention should be initiated before surgery and continued postoperatively Chemoprophylaxis with unfractionated or low molecular weight heparin should be strongly considered in addition to mechanical prophylaxis. The first dose should be administered within 12 hours of surgery and may be continued after discharge Nutritional assessment by history and laboratory screening is advised to detect anemia and protein malnutrition Body contouring should only be performed in accredited inpatient or outpatient facilities Intraoperative hypothermia should be prevented with the use of forced-air warming blankets, warming intravenous or injectable fluid, or raising the room temperature Particular attention should be paid to patient positioning and prevention of compression injuries. When prone, the patient should be placed in 15 degrees of reverse Trendelenberg to decrease intraocular pressure 440 Volume 28 Number 4 July/August 2008 Aesthetic Surgery Journal

5 assistance the day of surgery and at least three times per day thereafter. Compression boots are worn when the patient is not ambulating until the time of discharge. LMWH is started within 12 hours of surgery and maintained for 7 days. Incentive spirometry is encouraged, and patients are taught to use their machines 10 times per hour while awake. Once discharge criteria are met, the patient is sent home with instructions. CONCLUSION Obesity is a complex multifactorial disease that requires a specific subset of knowledge to optimize patient care and safety. Although the current study is limited by a relatively small database, we hope that with continual growth in the field of body contouring and more collective experience, guidelines may be further developed to optimize care in this patient population. In addition, multidisciplinary teams may further assist in improving overall care of bariatric surgery patients. A summary of current literature guidelines is provided in Table 2. DISCLOSURES The authors have no disclosures with respect to the contents of this article. REFERENCES 1. American Obesity Association. Obesity in the United States. (Accessed 4/19/2008, at 2. Aly AS, Cram AE, Chao M, Pang J, McKeon M. Belt lipectomy for circumferential truncal excess: The University of Iowa experience. Plast Reconstr Surg 2003;111: Arthurs ZM, Cuadrado D, Sohn V, Wolcott K, Lesperance K, Carter P, et al. Post-bariatric panniculectomy: Pre-panniculectomy body mass index impacts the complication profile. Am J Surg 2007;193: Borud LJ, Warren AG. Body contouring in the postbariatric surgery patient. J Am Coll Surg 2006;203: Borud LJ, Warren AG. Modified vertical abdominoplasty in the massive weight loss patient. Plast Reconstr Surg 2007;119: Colwell AS, Borud LJ. Autologous gluteal augmentation after massive weight loss: Aesthetic analysis and role of the superior gluteal artery perforator flap. Plast Reconstr Surg 2007;119: Duff CG, Aslam S, Griffiths RW. Fleur-de-lys abdominoplasty A consecutive case series. Br J Plast Surg 2003;56: Manahan MA, Shermak MA. Massive panniculectomy after massive weight loss. Plast Reconstr Surg 2006;117: Nemerofsky RB, Oliak DA, Capella JF. Body lift: An account of 200 consecutive cases in the massive weight loss patient. Plast Reconstr Surg 2006;117: Rohrich RJ, Gosman AA, Conrad MH, Coleman J. Simplifying circumferential body contouring: The central body lift evolution. Plast Reconstr Surg 2006;118: Shermak MA, Chang D, Magnuson TH, Schweitzer MA. An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Plast Reconstr Surg 2006;118: Shermak MA, Chang DC, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg 2007;119: Strauch B, Herman C, Rohde C, Baum T. Mid-body contouring in the post-bariatric surgery patient. Plast Reconstr Surg 2006;117: Clements RH, Katasani VG, Palepu R, Leeth RR, Leath TD, Roy BP, et al. Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. Am Surg 2006;72: Xanthakos SA, Inge TH. Nutritional consequences of bariatric surgery. Curr Opin Clin Nutr Metab Care 2006;9: Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann Plast Surg 2004;52: Aly AS. Body contouring after massive weight loss. St. Louis, MO: Quality Medical Publishing; 2006: Borud LJ. Combined procedures and staging. In: Rubin JP, Matarasso A, eds. Aesthetic surgery in the massive weight loss patient. Philadelphia: Elsevier; Aly A, Downey SE, Eaves FF III, Kenkel JM. Panel discussion Evolution of body contouring after massive weight loss. Plast Reconstr Surg 2006;118(Abstract Suppl): Payne CE, Southern SJ. Urinary point-of-care test for smoking in the pre-operative assessment of patients undergoing elective plastic surgery. J Plast Reconstr Aesthet Surg 2006;59: Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LJ, Kenler HA, et al. Are vitamin B12 and folate deficiency clinically important after roux-en-y gastric bypass? J Gastrointest Surg 1998;2: Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LB, Kenler HA, et al. Prophylactic iron supplementation after Roux-en-Y gastric bypass: A prospective, double-blind, randomized study. Arch Surg 1998;133: Lauder GR. Pre-operative predeposit autologous donation in children presenting for elective surgery: A review. Transfus Med 2007;17: Kulej M, Wall A, Dragan S, Krawczyk A, Romaszkiewicz P. The value of autotransfusion in the management of intraoperative blood loss during orthopedic surgery. Ortop Traumatol Rehabil 2006;8: Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:338S 400S. 26. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg 2004;114:43E 51E. 27. Roderick P, Ferris G, Wilson K, Halls H, Jackson D, Collins R, et al. Towards evidence-based guidelines for the prevention of venous thromboembolism: Systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis. Health Technol Assess 2005;9: Bergqvist D. Venous thromboembolism: A review of risk and prevention in colorectal surgery patients. Dis Colon Rectum 2006;49: Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest 2003;124:379S 385S. 30. Zhao J, Luo AL, Xu L, Huang YG. Forced-air warming and fluid warming minimize core hypothermia during abdominal surgery. Chin Med Sci J 2005;20: Ng V, Lai A, Ho V. 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6 39. Kulber DA, Bacilious N, Peters ED, Gayle LB, Hoffman L. The use of fibrin sealant in the prevention of seromas. Plast Reconstr Surg 1997;99: Vanounou T, Pratt W, Fischer JE, Vollmer Jr CM, Callery MP. Deviationbased cost modeling: A novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg 2007;204: Beaupre LA, Cinats JG, Senthilselvan A, Lier D, Jones CA, Scharfenberger A, et al. Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway. Qual Saf Health Care 2006;15: Yeats M, Wedergren S, Fox N, Thompson JS. The use and modification of clinical pathways to achieve specific outcomes in bariatric surgery. Am Surg 2005;71: Accepted for publication March 24, Reprint requests: Loren J. Borud, MD, 110 Francis St., Ste 5A, Boston MA lborud@bidmc.harvard.edu. Copyright 2008 by The American Society for Aesthetic Plastic Surgery, Inc X/$34.00 doi: /j.asj Volume 28 Number 4 July/August 2008 Aesthetic Surgery Journal