The Changing Body After Bariatric Surgery Plastic Surgery & Other Options. Al Aly, MD, FACS

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1 The Changing Body After Bariatric Surgery Plastic Surgery & Other Options Al Aly, MD, FACS Professor of Plastic Surgery Director of Aesthetic Plastic Surgery University of California Irvine Overview Why I specialize in MWL Plastic Surgery Educate you about Body Contouring after Massive Weight Loss Questions and Answers 1

2 I have been doing MWL Plastic Surgery longer than anybody in the world How can that be? A Little History 2

3 Bariatric Surgery was fathered at the University of Iowa back in the 60s and 70s by a Dr. Mason But it was not popular because of lack of refinement till

4 The field of body contouring after massive weight loss did not exist then A few places had MWL patients and Iowa was one of them Because of Mason 4

5 When I started my practice at the University of Iowa there was a back log of MWLPs Forced by patient demand Invented or Developed plastic surgery procedures utilized world wide today 5

6 Dr. Aly published the first textbook ever written on the subject The BIBLE It has been sold or illegally copied all over the world 6

7 List of countries where I lectured and/or operated US (extensively) Canada Costa Rica Brazil Argentina Mexico Colombia Dubai Qatar New Zealand Saudi Arabia Germany Spain Turkey Portugal Russia Kuwait Egypt Belgium India Australia I am passionate and I care very much 7

8 What happens with weight loss after obesity? The skin acts like a balloon, it expands 8

9 When people lose weight Some patient s balloon returns to normal size What happens when you gain weight then lose it? Some patients skin expands past its limits and loses its elasticity 9

10 They end up with Loose excessive skin Most MWLP will not go back to normal after their weight loss 10

11 Presentation of the MWLP is extremely variable 11

12 If all treated the same way Results are inferior 12

13 Factors That Affect RESULTS Weight or BMI at presentation Fat deposition pattern Quality of skin-fat envelope 13

14 Apple Pear 14

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16 Mind-Set at Presentation Dear Dr, I use to weight 350 pounds and felt extremely bad about it, my health was awful, I could hardly get around... I had gastric bypass surgery 2 years ago and lost 200 pounds... Unfortunately, I still look and feel fat. I have worked so hard to get to where I am but I feel that it might have been all for nothing. Can you help me? I still look and feel fat 16

17 Four Major Regions Lower trunk Upper arms Thorax Thighs Massive weight loss patients have circumferential lower truncal excess in the shape of an inverted cone 17

18 The Inverted Cone 18

19 Treatment Options T shaped lipectomy Abdominoplasty Circumferential lipectomy T Shaped Panniculectomy May lead to bizarre contours 19

20 T Shaped Panniculectomy Even when done well has no effect on the sides or back 20

21 PostOp: False Age: 39 PostOp: False Age: 39 No back or buttocks improvements 21

22 Tummy Tuck Ideally treats Mild excess belly fat Excess belly skin Belly laxity 22

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24 Tummy Tuck only in a massive weight loss patient Bulge or Dog Ear Tummy Tuck only in a massive weight loss patient No back or buttocks improvements 24

25 Tummy Tuck only in a massive weight loss patient Bulge or Dog Ear Tummy Tuck only No back or buttocks improvements 25

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27 Rehabilitation of the lower trunk in the massive weight loss patient most often requires circumferential treatment A Tummy Tuck is like a conventional weapon A BELT LIPECTOMY is like a NUCLEAR WEAPON 27

28 = Tension Tension=Improvement = Improvement Tension = Improvement away from closure 28

29 0 Tension No back or buttocks skin tightening 29

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34 Why Circumferential? Eliminates Pubic area excess Tummy bulges and aprons Outer and lower back excess Buttocks droopiness Lifts the outer and front thighs Increases buttocks definition Creates a waist 34

35 Pubic Area Abdomen 35

36 Outer & Lower back Waist 36

37 Buttocks Buttocks 37

38 Front & Outer Thighs BODY LIFT Belt lipectomy Lower body lift Central body lift Circumferential abdominoplasty Torsoplasty 38

39 Body Lifts Are Not All The Same Approaches to The Trunk Lower Body Lift Belt Lipectomy 39

40 Lower body lift = Low Belt lipectomy = high Lower body lift = Low 40

41 Belt lipectomy = high 41

42 The cinching leads to an illusion of increased projection 42

43 Criteria For Surgery Medically healthy Psychiatric stability Non-smoker Reduced intra-abdominal content Stable weight for ~3 to 6 months 43

44 Heroic efforts to lose weight are counter productive 44

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46 Belt Lipectomy/Body lift PostOp: False Age: 48 46

47 3 to 6 hours Belt Lipectomy Requires two turns in the OR Recovery- 3 to 6 weeks Should be approached as a major life event Massive Weight Loss Generally, results correlate with the patient s BMI at surgery 47

48 Expected Results High BMI 48

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53 Expected Results Intermediate BMI 53

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58 Expected Results Near ideal BMI 58

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64 Upper arm excess in the MWLP 64

65 PostOp: False Age: 48 In massive weight loss patients the excess crosses the axilla (armpit), onto the lateral chest wall Thus, upper arm reduction or Brachioplasty must account for that 65

66 General Physical Presentations Upper Arms The excess crosses the axilla The excess is the posterior axillary fold Different amounts of retained fat 66

67 PostOp: False Age: 40 The Posterior Axillary fold Presentation If greatly deflated ideal If significantly inflated preliminary liposuction & staged excision If intermediate decision has to be made with patient 67

68 Brachioplasty in the MWLP SHOULD CROSS THE AXILLA and follow the defect 68

69 PostOp: False Age: 40 The Double Ellipse Technique 69

70 Brachioplasty Results Why Doesn t The Traditional T Approach Work 70

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75 PostOp: False Age: 25 75

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78 Upper Arm Complications Seroma Lymphocele/lymphedema Inability to close the arm Bad scarring Infection/Bleeding Nerve compression/sensory loss Upper Body Lifts treats Entire Chest Deformity 78

79 Thorax The Normal Position 79

80 The Normal Position Thoracic Deformities 80

81 General Physical Presentations Thorax-upper truncal subunit An analogy - expansion and then deflation of a lamp shade that is tethered at two points Horizontal excess extension of the upper arm excess Vertical excess 81

82 Upper Body Lift Results 82

83 PostOp: False Age: 22 83

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85 PostOp: False Age: 24 PostOp: False Age: 24 85

86 PostOp: False Age: 25 PostOp: False Age: 25 86

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98 Thigh Reductions 98

99 PostOp: False Age: 25 PostOp: False Age: 32 99

100 Thigh Reduction in the MWLP Mostly a vertical excision Occasionally a horizontal component This approach follows the defect 100

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105 Insurance does not cover much past the hanging belly 105

106 Consider working on finance EARLY should you need it Be realistic in your expectations 106

107 Greater rate of complications BEWARE & BE AWARE Body contouring after MWL is highly specialized 107

108 Be a WISE CONSUMER when it comes to plastic surgery after MWL Summary Skin acts like a balloon Body lifts are required Body lifts are not all the same Arm reduction to chest wall 108

109 Summary Upper body needs an UBL The thighs are hard Realistic expectations Higher rate of complications Summary Insurance doesn t cover So PLAN Be a wise consumer 109

110 Plastic Surgery can be a LIFE TRANSFORMATION 110

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112 I still look and feel fat 112

113 Bariatric surgery gave me back my life, the plastic surgery that I had allowed me to enjoy it 113

114 End Al Aly, MD, FACS 114