Desire for Body Contouring Surgery After Bariatric Surgery: Do Body Mass Index and Weight Loss Matter?

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1 INTERNATIONAL CONTRIBUTION Body Contouring Desire for Body Contouring Surgery After Bariatric Surgery: Do Body Mass Index and Weight Loss Matter? Aesthetic Surgery Journal 2014, Vol 34(1) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Salvatore Giordano, MD; Mikael Victorzon, MD, PhD; Teija Stormi, BSocSc; and Erkki Suominen, MD, PhD Abstract Background: There is disparity between the number of postbariatric surgery subjects who desire body contouring and those who receive it due to lack of resources or insurance criteria. Objectives: The authors evaluate the desire for body contouring after bariatric surgery and its relationship with demographic patient characteristics. Methods: Three hundred sixty patients who had undergone bariatric surgery procedures >1 year previously completed a questionnaire designed by the surgical team to analyze each patient s desire for body contouring by area (face, upper arm, upper back, chin/neck, chest/breast, waist/abdomen, lower back, rear/buttock), scored from 0 to 3 (do not want, want somewhat, want, want a great deal). Data were compared with patient characteristics, postoperative body mass index (BMI), amount of weight loss, and BMI difference (ΔBMI). Results: Most patients desired body contouring surgery, with high or very high desire for waist/abdomen (62.2%), upper arm (37.6%), chest/breast (28.3%), and rear/buttock (35.6%) contouring. Many patients (36.4%) cited very high expectations for how body contouring might change their appearance. Patients >50 years old and >3 years postsurgery had a significantly lower desire. Patients with a ΔBMI >10 and with a weight loss >20 kg showed a significantly stronger overall desire for body contouring compared with other groups. Conclusions: Most patients desire body contouring surgery after bariatric surgery, and our multivariate analysis showed a significant positive association between female sex, younger age, amount of weight loss, and ΔBMI with desire for body contouring. Keywords obesity, body contouring, massive weight loss, body contouring indications, postbariatric surgery, patient preferences, questionnaire Accepted for publication May 29, Bariatric surgery frequency has been increasing in proportion to the growing incidence of morbid obesity. 1 Paralleling the increase in bariatric surgery, there is also a greater desire for body contouring surgery. Body contouring surgery seems to improve quality of life, self-esteem, and body image 2-10 over the long term. 5,10 Only 1 study 7 showed that patients who elected to have body contouring after bariatric surgery had decreased quality of life compared with those patients who did not. Indeed, body contouring surgery not only improves the aesthetic outcome of bariatric surgery but also corrects functional impairment. 2-5,9 A number of studies have shown that from 25% up to 54% and as many as 84.5% of postbariatric patients desire body contouring, but only 21% to 25% actually undergo these procedures However, the majority of patients would be willing to undergo body contouring procedures in the future In Finland, only 7% of bariatric surgery patients underwent abdominoplasty in a public hospital between 2000 and 2007, according to the National Registry. 16 Dr Giordano is a Resident in Plastic Surgery and Dr Suominen is an Assistant Professor of Plastic Surgery in the Department of Plastic and General Surgery, Turku University Hospital, Turku, Finland. Dr Victorzon is a Gastrointestinal Surgeon and Professor of Surgery in the Department of Surgery, Vaasa Central Hospital, Vaasa, Finland. Dr Stormi is a Biostatistician in the Department of Biostatistics, University of Turku, Turku, Finland. Corresponding Author: Dr Salvatore Giordano, Department of Plastic and General Surgery, Turku University Hospital, OS 299, PL 52, 20521, Turku, Finland. salvatore.giordano@gmail.com

2 Giordano et al 97 In the literature, there are few clear guidelines for the management of this constantly rising patient population. Furthermore, increasing working-hour limitations and tight health care budgets have posed significant challenges for treating them. Hence, it is important to clarify this relevant issue, particularly concerning the indications for postbariatric body contouring surgery. Therefore, we took the opportunity to evaluate patients desire for body contouring after bariatric surgery procedures, to examine which body regions were associated with the greatest levels of dissatisfaction, to summarize patients expectations from postbariatric procedures, and to correlate these subjective reports with patients demographic characteristics, postoperative body mass index (BMI), amount of weight loss, and difference in BMI (ΔBMI). Methods Study approval was granted by the ethical committee of Vaasa Central Hospital, Vaasa, Finland. We included only patients who had undergone bariatric surgery for morbid obesity in a single bariatric surgery institution (Vaasa Central Hospital) between 2002 and 2010, had maintained a stable weight for at least 1 year, and had not undergone any body contouring procedures. Patients who had undergone massive weight loss (MWL) without bariatric surgery were excluded. A stable weight was defined as weight with a maximum of plus or minus 5 kg from the weight measured at the bariatric surgery follow-up. A Postbariatric Surgery Appearance Questionnaire (Appendix 1, available at com) previously developed 13 and modified for the purposes of the study was mailed to 524 patients who met inclusion criteria. This self-reported questionnaire took approximately 15 minutes to complete. It contained questions on demographics (age, sex, weight pre- and postbariatric surgery), level of desire for body contouring per area (face, upper arm, upper back, chin/neck, chest/ breast, waist/abdomen, lower back, rear/buttock) scored from 0 to 3 (do not want, want somewhat, want, want a great deal), and degree of expected improvement from body contouring surgery (none, very low, low, somewhat, high, very high). Questionnaire data were compared with patient characteristics, type of bariatric procedure, postoperative BMI at follow-up, amount of weight loss, and ΔBMI. Those data were retrieved from our institutional bariatric surgery database. Patients were stratified into groups based on age, the amount of weight loss, and ΔBMI. Statistical Analysis Categorical variables were characterized by frequencies and percents and continuous variables by means and standard deviation (SD). Statistical analyses were performed using linear models in which desire for body contouring Table 1. Demographics Data of 360 Patients Characteristic was used as a dependent variable and postoperative BMI, BMI, sex, age, and weight loss were used as a fixed effect. P values were adjusted using the Tukey-Kramer method in pairwise comparison between different classes of ΔBMI and weight loss amount. Residuals were checked for justification of the analysis. P values less than.05 were considered statistically significant. Statistical analyses were carried out using SAS system for Windows, version 9.2 (SAS Institute, Inc, Cary, North Carolina). Results Value Number of patients 360 Sex, F/M, No. (%) 250 (69.44)/110 (30.56) Age, mean (SD), y ± Follow-up after bariatric surgery, mean (SD), mo ± Preoperative BMI, mean (SD), kg/m² ± 6.38 Postoperative BMI, mean (SD), kg/m² ± 6.04 Weight loss, mean (SD), kg ± Procedure, No. (%) Gastric banding 161 (44.72) Gastric bypass 165 (45.83) Sleeve gastrectomy 31 (8.61) Biliopancreatic diversion 3 (0.83) BMI, body mass index. Three hundred sixty patients (69%) completed the questionnaire. Patients characteristics are shown in Table 1. There were 110 men and 250 women respondents, with a total mean age of ± years. Mean preoperative BMI was ± 6.38 kg/m 2 and mean postoperative BMI was ± 6.04 kg/m 2. Bariatric surgery procedures included gastric bypass in 46% of responders, gastric banding in 45%, and sleeve gastrectomy or biliopancreatic diversion in the other 9% of the patients. Mean postoperative follow-up was ± months, mean weight loss was ± kg, and mean ΔBMI was ± 6.89 kg/m 2 (Table 1). Of the 164 patients who did not respond to the questionnaire (nonresponders), 65.6% were women; their highest mean lifetime BMI was ± 4.31 kg/m 2 and mean age was ± There were no statistically significant differences in patient age, postoperative BMI, or sex proportion between responders and nonresponders.

3 98 Aesthetic Surgery Journal 34(1) Table 2. Desire of Body Contouring Surgery per Body Area (Frequency and Percentage) Desire for Surgery Do Not Want Want Somewhat Want Want a Lot Face a 294 (83.29) 18 (5.10) 13 (3.68) 28 (7.93) Chin/neck a 256 (72.52) 34 (9.63) 29 (8.22) 34 (9.63) Upper arm b 179 (50.56) 42 (11.86) 48 (13.56) 85 (24.01) Upper back b 322 (90.96) 14 (3.95) 14 (3.95) 4 (1.13) Chest/breast b 227 (64.12) 27 (7.63) 37 (10.45) 63 (17.8) Waist/abdomen b 97 (27.40) 37 (10.45) 52 (14.69) 168 (47.46) Lower back b 310 (87.57) 24 (6.78) 11 (3.11) 9 (2.54) Rear/buttock b 188 (53.11) 40 (11.30) 43 (12.15) 83 (23.45) a Seven frequencies missing. b Six frequencies missing. Figure 1. Mean desire for body contouring surgery by body region. Most patients desired body contouring surgery, often in several areas, with high or very high desire in waist/ abdomen (62.2%), upper arms (37.6%), chest/breast (28.3%), and rear/buttock (35.6%; Table 2). Only 15.5% of patients did not desire any postbariatric plastic surgery procedure. Mean desire values by body region are shown in Figure 1. Two multivariate models were used, excluding in turn weight loss and ΔBMI to avoid possible multicollinearity and because weight loss and ΔBMI strongly correlate with each other. In a first statistical multivariate model, there was a significant positive association between desire for body contouring surgery and female sex (β = 3.56; 95% confidence interval [CI], 4.52 to 2.61; P <.0001), younger age (β = 0.09; 95% CI, 0.13 to 0.05; P <.0001), and amount of weight loss (β = 0.05; 95% CI, 0.02 to 0.070; P =.0004) but not postoperative BMI (β = 0.12; 95% CI, 3.05 to 0.07; P =.139). In a second statistical model, multivariate analysis revealed a significant positive association between female sex (β = 3.31; 95% CI, 4.25 to 2.37; P <.0001), younger age (β = 0.09; 95% CI, 0.14 to 0.05; P <.0001), and ΔBMI (β = 0.12; 95% CI, 0.05 to 0.20; P =.0009) but not postoperative BMI (β = 0.13; 95% CI, 3.54 to 0.98; P =.0774) with desire for body contouring. When patients were stratified by age groups, the desire for body contouring in many different areas decreased, while it remained constant in face and chin/neck areas with increasing age (Figure 2A-H). Similarly, when patients were stratified by weight loss groups, the desire for surgery in abdomen, lower back, and rear/buttock areas increased but remained similar in the other parts of the body (Figure 3A-H). Patients older than 50 years showed a significantly decreased desire for body contouring surgery (Table 3). Also, a significant decrease in the desire for plastic surgery procedures was detected after 36 months from bariatric surgery when patients were stratified by follow-up (Table 3). Patients with a ΔBMI >20 showed a significantly stronger overall desire for body contouring compared with ΔBMI 5 and 5 < ΔBMI 10. Patients with a weight loss >50 kg showed a significantly stronger overall desire for body contouring compared with weight loss <20 kg (Table 4). There was no significant correlation or difference between desire and mean time since bariatric surgery or type of bariatric procedure. Finally, 36.4% of all respondents had a very high overall expectation for the ways in which body contouring surgery would improve their appearance (Figure 4). There was a significant correlation between the overall expectation for plastic surgery procedures and younger age (ρ = 0.125, P =.019) but not female sex (ρ = 0.040, P =.455), weight loss amount (ρ = 0.023, P =.668), ΔBMI (ρ = 0.015, P =.777), follow-up (ρ = 0.06, P =.205), or desire (ρ = 0.077, P =.151). Discussion In the present study, we aimed to explore the desire for body contouring surgery after bariatric surgery for morbid obesity in a single bariatric surgery institution, in patients with a stable weight for at least 1 year who had not undergone any body contouring procedures. Our results provide valuable insight into patients personal views and experience with detailed data concerning age, follow-up, amount of weight loss, and ΔBMI. Although reductions in comorbidity after bariatric surgery are common, patients are often still unhappy with their bodies Thus, these patients are often highly motivated to seek and undergo body contouring surgery. 13,14 Our study showed that the majority of postbariatric surgery patients desire body contouring procedures, often in

4 Giordano et al 99 Figure 2. Desire for body contouring surgery in different age groups per each body area: face (A), chin/neck (B), upper arm (C), upper back (D), chest/breast (E), waist/abdomen (F), lower back (G), and rear/buttock (H).

5 100 Aesthetic Surgery Journal 34(1) Figure 2. (continued) Desire for body contouring surgery in different age groups per each body area: face (A), chin/neck (B), upper arm (C), upper back (D), chest/breast (E), waist/abdomen (F), lower back (G), and rear/buttock (H). several areas, especially the abdomen, upper arm, chest/ breast, and rear/buttock. We found a significant association between female sex, younger age, amount of weight loss, and ΔBMI with desire for body contouring. There have been several previous studies on this topic 11-15,17 involving from to questionnaire participants. All but 1 study 12 also included patients who previously underwent body contouring procedures, from 3.2% to 47% 11,13-15,17 of the study population. In our study, we excluded patients who had been treated by postbariatric plastic surgery previously to assess level of desire and to compare that with objective measurements like weight loss and BMI difference. For these reasons, we also omitted the parts of the questionnaire 13 concerning satisfaction with appearance after body contouring surgery, and we added the question about overall degree of expectation from plastic surgery procedures in terms of aesthetic outcomes. 18 Steffen et al 17 did not find any correlation between desire and age, sex, follow-up, or BMI change. Gusenoff et al 14 found an inverse correlation between desire and age as well as years since gastric bypass. They also showed a positive correlation between desire and female sex and marital status (divorced vs married individuals), which is in concordance with the findings in this study, where a significant correlation was found between the desire for postbariatric surgery and younger age, female sex, amount of weight loss, and difference in BMI. Interestingly, desire for a plastic surgery procedure did not decrease in the face and chin/neck areas with the increase of age (Figure 2A), while it decreased for the other areas, especially in patients older than 50 years (Figure 2B-H). Another interesting finding is that patients had a lower interest in body contouring procedures not only with increasing age but also with an increasing time period after bariatric surgery (ie, after 3 years follow-up from primary bariatric surgery; Table 3). The desire for postbariatric body contouring surgery has been focused mostly on the abdomen, upper arm and thighs, or breast areas in previous publications ,15 We confirmed these findings (Figure 1), and we suggest that brachioplasty should be taken into consideration as a reconstructive procedure after MWL. 19 We assumed that patients who lost more than 50 kg and/or had a ΔBMI over 20 would have a stronger desire for body contouring surgery. Thus, we divided patients in groups on the basis of the amount of weight loss and ΔBMI. Patients with a ΔBMI >20 showed a significantly stronger overall desire for body contouring compared with ΔBMI 5 and 5 < ΔBMI 10. Patients with a weight loss >50 kg showed a significantly stronger overall desire for body contouring compared with weight loss <20 kg. Therefore, we found a relationship between desire for body contouring and both the amount of weight loss and ΔBMI (Table 4). These findings indicate that a ΔBMI >10 and weight loss 20 kg might serve as cutoff values for postbariatric surgery indication. Postbariatric plastic surgery aims to treat both the functional and aesthetic problems caused by surplus skin, increasing the patient s quality of life and self-esteem. 2-10,14,15 These patients generally have very high expectations for both aesthetic outcomes and improved quality of life, 18 and our findings confirm this (Figure 4). Many of the surgical procedures performed on MWL patients are complex, are labor-intensive, and carry higher complication rates. 20,21 It has been demonstrated that postbariatric surgery patients undergoing body contouring procedures present higher risk for venous thromboembolism, 22 hypothermia, 23 baseline anemia, 24 nutritional deficiencies, 25,26 and wound healing impairment. 27,28 Hence, body contouring surgery cannot be delivered to all postbariatric patients.

6 Giordano et al 101 Figure 3. Desire for body contouring surgery in different weight loss groups per body area: face (A), chin/neck (B), upper arm (C), upper back (D), chest/breast (E), waist/abdomen (F), lower back (G), and rear/buttock (H).

7 102 Aesthetic Surgery Journal 34(1) Figure 3. (continued) Desire for body contouring surgery in different weight loss groups per body area: face (A), chin/neck (B), upper arm (C), upper back (D), chest/breast (E), waist/abdomen (F), lower back (G), and rear/buttock (H). Table 3. Patients Desire for Body Contouring Into Different Classes of Age and Follow-up Age, y Frequency, No. (%) Desire, Mean ± SD (Range) P Value a Follow-up, mo Frequency, No. (%) Desire, Mean ± SD (Range) P Value b (3.89) 8.86 ± 4.55 (0-16) >12 and (21.67) 6.81 ± 4.43 (0-18).007 >30 and (11.11) 8.00 ± 4.21 (0-18).524 >18 and (19.17) 5.32 ± 4.62 (0-16).495 >40 and (26.39) 7.31 ± 4.85 (0-17).263 >24 and (38.61) 6.55 ± 4.91 (0-18).012 >50 and (29.72) 5.11 ± 4.12 (0-18).002 >36 74 (20.55) 4.71 ± 4.26 (0-17) > (28.89) 4.49 ± 4.48 (0-18).001 a Calculated as patients with an age 30 versus other classes. P values were adjusted using the Tukey-Kramer method. b Calculated as patients with a follow-up >36 months versus other classes. Generally, elective body contouring surgery should be delayed in this population until weight has stabilized for a minimum of at least 3 months after a weight loss plateau is reached generally 12 to 18 months after bariatric surgery. 29 A stable weight prior to body contouring surgery in postbariatric patients results in a significantly lower complication rate. 29,30 Indeed, a BMI <30 kg/m 2 is believed to be associated with fewer complications in postbariatric plastic surgery There are discrepancies between patients who receive and who do not receive body contouring surgery after MWL, 11,13,15 which might be attributed to social status. 14 These procedures are not covered by third-party payers in the United States; body contouring procedures or operations are usually restricted to abdominal problems and only panniculectomies are covered. In addition, most patients cannot afford the cost of the surgery. 36,37 Public insurance in other countries may offer and cover body contouring procedures, but decisions must be supported by appropriate indications. 36,37 In a recent survey from the United Kingdom, 38 only 22% of doctor respondents reported that their patients with skin redundancy were able to access a plastic surgeon. No clear criteria for referral were found, and only a limited number of bariatric surgeons offer body contouring. 38 A similar survey from the United States, 39 where the health care system is insurance based, showed that 87% of bariatric surgeons believe that deformities after MWL are both functional and aesthetic. At present, there are no studies where clear criteria for postbariatric body contouring have been addressed and insurance coverage might not be as beneficial or available as it may seem. Thus, there is definitely a need for developing guidelines, possibly evidence based. In southeast Scotland, 12 guidelines include severe, intractable intertrigo beneath the skin fold; MWL; a BMI 27; significant weight loss resulting in functional problems; lipodystrophy; and as an adjunct to reconstructive procedures. In Austria, 15,40 body contouring surgery is covered by public insurance when there is a weight loss of more than 30% of the patient s original weight and if the patient concomitantly manifests other symptoms (ie, spinal overload, eczema, infections, lymphedema, psychological problems). However, inclusion criteria are not always clear. In Finland, a scoring system for abdominoplasty indications has been

8 Giordano et al 103 Table 4. Patients Desire for Body Contouring Into Different Classes of ΔBMI and Weight Loss Amount ΔBMI, kg/m 2 Frequency, No. (%) Desire, Mean ± SD (Range) P Value a Weight Loss, kg Frequency, No. (%) Desire, Mean ± SD (Range) P Value b 5 42 (11.67) 4.41 ± 4.52 (0-17).001 <20 70 (19.44) 4.46 ± 4.26 (0-17).007 >5 and (25.28) 4.98 ± 4.28 (0-18) and (24.17) 5.94 ± 4.85 ( >10 and (33.33) 6.54 ± 4.70 (0-17).133 >30 and (21.39) 6.49 ± 4.11 (0-18).424 >15 and (18.61) 6.22 ± 4.57 (1-18).094 >40 and (17.50) 6.32 ± 4.88 (2-18).283 >20 40 (11.11) 8.48 ± 4.34 (1-18) >50 63 (17.50) 7.19 ± 4.74 (2-18) a Calculated as patients with a body mass index difference (ΔBMI) >20 kg/m 2 versus other classes. P values were adjusted using the Tukey-Kramer method. b Calculated as patients with a weight loss >50 kg versus other classes. Figure 4. Expectations from body contouring surgery. developed. It is based on skin symptoms (ie, recurrent cellulitis), weight stability (over 6 months), and a BMI less than 32, regardless of the weight loss methods. 41 In Sweden, 41 abdominoplasty in postbariatric surgery patients is indicated if the panniculus hangs over 3 cm when the patient has a stable BMI <30 kg m 2. Similarly, in Denmark, the patient must have a BMI <30 kg/m 2 and a ΔBMI >15. In particular cases with a BMI over 30 kg/m 2, only panniculectomy is indicated, 41 but our data indicate that surgery procedures other than panniculectomy/abdominoplasty are often desired (ie, brachioplasty). We believe that total weight loss and BMI difference (ΔBMI) are more important criteria for assessment than standard BMI. In fact, we did not find a significant association between postoperative BMI at follow-up and desire for postbariatric plastic surgery procedures. We do believe that a weight loss more than 20 kg and a ΔBMI >10 kg/m 2 might be considered for selecting patients for body contouring surgery in a public health care insurance system. The limitations of the present study include the subjective nature of the questionnaire, which has not yet been validated, and the response rate of 69%, which might reflect a self-reporting bias. We did not carry out a test-retest to evaluate the reliability of the questionnaire, as a similar one has already been used by Mitchell et al. 13 Nevertheless, we were not able to consider the possible impact of patients comorbidities as well as their underestimation of physical symptoms in our results due to lack of data. In total, 164 patients did not respond to the questionnaire, and although there were no statistically significant demographic differences between responders and nonresponders, it is not possible to say how their answers would have affected the results of this study. It is also possible that patients who were more dissatisfied with their appearance were more likely to take part in this study. In addition, the results may have been affected by the fact that women usually have a lower threshold for unacceptable appearance than men. Previous pregnancies may also play a role. These proposed metrics give no insight as to whether patients who meet these criteria for surgical indication would actually benefit from such, and they do not take into account medical issues and comorbidities. The frequency of bariatric surgery continues to rise, resulting in a growing postbariatric patient population seeking body contouring procedures. Thus, additional research is needed, especially in the area of body contouring indications after MWL. In particular, prospective studies that include objective patient assessments and better qualification/quantification of the problem are clearly necessary. Conclusions Most patients desire body contouring surgery after bariatric surgery, and they should not be denied on the basis of BMI alone. Our study provides an insight into patients personal views and experience, with detailed data concerning age, follow-up, amount of weight loss, and ΔBMI. Patients with a ΔBMI >10 and weight loss 20 kg have a stronger desire for body contouring plastic surgery, and we believe these data may be valuable for establishing medical and insurance guidelines for coverage. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article.

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