ABDOMINOPLASTY FOR PATIENT WHO HAS UNDERGONE GASTRIC BYPASS SURGERY UAB HOSPITAL, BIRMINGHAM, AL Broadcast June 20, 2005

Transcription

1 NARRATOR ABDOMINOPLASTY FOR PATIENT WHO HAS UNDERGONE GASTRIC BYPASS SURGERY UAB HOSPITAL, BIRMINGHAM, AL Broadcast June 20, :00:14:00 Over the next hour, surgeons at UAB Hospital at the University of Alabama at Birmingham will perform an abdominoplasty on a bariatric patient who has lost significant weight. A year or more after undergoing gastric bypass surgery, patients may be left with excess skin which can cause a host of medical problems. The skin must be removed to avoid pain, infection and skin irritation. 00:00:38:00 I think UAB is one of the finest medical institutions and finest surgical centers in the United States and in the world. I have had people come to UAB from instate, out of state and even from other countries and they re all very pleasantly surprised by the quality of the work overall and the quality of our facilities and the effectiveness of our jobs. NARRATOR 00:01:10:00 You may questions to the physicians in the OR by clicking the MDirectAccess button at any time. This program represents UAB Hospital s ongoing efforts to bring the latest developments in healthcare to the community. 00:01:34:00 This is a live view of Operating Room #705 at the University of Alabama at Birmingham. Today we ll be viewing an abdominoplasty being performed on a gastric bypass patient. I m Dr. James Long, assistant professor of plastic and reconstructive surgery at the University of Alabama at Birmingham. Today we ll be discussing many aspects of abdominoplasty and we ll be hearing from a patient who has had an abdominoplasty performed in the past. I d like to introduce you to my good friend and colleague, Dr. John Anastasatos, who ll be performing the operation today. Before I hand you off to him, though, I d like to encourage you to ask questions during the webcast. You can do this by clicking the MDirect button at the bottom of your screen. For those of you who are viewing this operation for CME credit, at the end of the procedure, there ll

2 be a button that you can press on your computer screen to allow you to get CME credit for the course. Now let me hand things off to John. John? 00:02:36:00 Good morning. I m Dr. John Anastasatos, plastic surgeon at UAB and what we re doing today is we ll perform an abdominoplasty on a lady who had gastric bypass about two years ago. She has lost 160 pounds. Since then she has developed significant abdominal lipodystrophy and sagginess of the breasts. We already have done a breast lift on her and now we re proceeding with the abdominoplasty. What you re seeing so far is we have lifted up a lot of the abdominal skin, all the way up to the costal margins. Underneath here, you see the muscular (inaudible) system of the abdomen and you can see that she has a significant laxity which happens after this operation. What we re going to do next is we re going to go ahead and tighten the muscles of the abdomen. This is the umbilicus that I m holding here. So, what I m going to do here this is the muscles underneath the abdomen they have been stretched out over time and because of the excessive weight and now we re going to go ahead and tighten them, we re going to plicate them. 00:04:46:00 So here John has outlined the areas that he plans to plicate to help tighten the musculofascial portion of the abdominal wall. This is a key portion of the procedure, particularly in patients who have a lot of musculofascial weakness. Later on we ll be removing skin and that s typically the part of the operation that most patients are interested in but there is actually a significant amount of work that goes on beneath the skin that oftentimes patients don t appreciate. This is a part of that right now and you ll see that as he places the sutures, the abdominal wall will be decreased in its circumference. 00:05:37:00 We have performed already a fair amount of work so far by this point, but there s actually a fair amount of planning that goes into this operation which begins actually outside the operating room. So, we d like to show you some of the preoperative markings that we have performed on a previous patient, if you could please introduce that. 00:06:11:00 Certainly, so what you see here on the screen is a previous patient who had gastric bypass, lost a significant amount of weight and this is the preoperative planning and marking that happened before his surgery. What you see in black ink is the area of skin that was actually excised in that individual and what you see in the purple ink is the presence of a hernia that that patient developed as a result of the previous surgery. That was an incisional hernia which we fixed at the same time as the abdominoplasty. This is one of the advantages or the benefits, if I may use that term, of doing that operation at the same time, we can address other problems that patients may have.

3 00:07:05:00 John, do you notice a difference in the incidence of hernia in patients who have different bariatric procedures applied? 00:07:15:00 I don t know the exact number, Jim, but I find the incidence to be much higher in patients who ve had gastric bypass, particularly the patients who have had the open technique, meaning through a midline incision in the abdomen, as opposed to the laparoscopic. What has been your experience? 00:07:36:00 I think that mirrors my experience also. Patients who have had open gastric bypass procedures I find have much higher incidence of hernia. Again, I couldn t tell you the exact number, but I find with the laparoscopic procedure far less incidence of hernia. I d say my experience in that regard mirrors yours. So I notice here on this video that we re showing that on this previous patient who d had abdominoplasty performed, you re doing a fleur-de-lis-type incision, you re taking both vertical and horizontal components. 00:08:22:00 That is correct. Different patients have different needs and oftentimes gastric bypass patients not only have excessive lipodystrophy in the vertical dimension, but also in the horizontal. It s good to try to address both issues, particularly in a patient like that who has a hernia. That exposure facilitates the repair. What you see there next is we are inject some solution that allows us to perform liposuction and we perform liposuction underneath the skin that we plan to excise and we do that because that facilitates the excision and the blood loss is less and the operation is faster and safer. Jim? And that s the actual liposuction procedure that you can see there. 00:09:30:00 Well, John, if I may, I have a few questions from persons who have logged on to the website and are interested in what we re doing here today. This is an interesting question, I think, germane to a lot of the viewers. The patient indicates that she s curious as to how much excess skin is needed to qualify. I m presuming she means qualify for insurance coverage for abdominoplasty. She indicates she s had significant weight loss and is not sure if she meets the criteria the insurance companies have set forth in order to be considered. Let me tell you what my experience has been, John, and then you can tell me if yours has been the same. My experience with the insurance companies has been that persons who have a significant overlapping of skin at the lower abdomen that is the result of the bariatric procedure that they ve had, once they ve achieved a stable weight and if they have medical complications such as rashes and the like underneath the

4 abdominal skin which has become a persistent problem for them, here in Alabama and I m presuming it s similar elsewhere, insurance companies will typically consider providing benefits for patients for a procedure known as panniculectomy, which is a more limited form of the abdominoplasty that we ll be seeing today. Now, having said that, we certainly perform abdominoplasty on persons who have minimal skin excess and they re interested in mostly having a more aesthetically pleasing contour to their abdomen and eliminating some of the signs of aging that are unfortunately attendant with getting a little bit older. Also seen in persons who have had numerous pregnancies and the like. So I don t think there s an absolute minimum that has to be met in order to be considered for abdominoplasty, however, in order for insurance companies to consider you for benefits, significant skin excess of your lower abdomen and complications from that skin such as rashes and the like. Has that been your experience also? 00:11:59:00 Yes, I agree with you, Jim. Per se, there s no specific weight amount of skin for patients to qualify. It has to do more with the problems that this excessive skin creates as a result of the massive weight loss. I find that the most frequent problems is that skin breakdown, irritation, rashes and limitation of simple activities of daily living. So I agree with the things you said, I don t think there is a particular amount of skin per se, it s the problems that it tends to create. 00:12:47:00 I have another question here from a potential patient who is interested in finding out if any of the surgeons here at the university perform lap-band procedure, the laparoscopic banding gastric bypass procedure. I was unfamiliar with the techniques utilized by one of our physicians who sends quite a number of his post-op patients our way, a gentleman by the name of Ronald Clements, and discuss with him the procedure that he uses to perform bariatric bypass. In fact, he does not use a banding procedure, where a portion of the stomach is banded off from the remainder of the stomach to reduce appetite. Instead he performs a Roux-en-Y gastric bypass procedure via the laparoscope. He s quite adept at it, he gets excellent results and I see a number of his patients in follow-up as I m sure you do. 00:13:49:00 Which leads into another question presented by another patient. About how long after the procedure do patients become a candidate for body contouring procedures like the one that we re performing today? My experience has been that typically patients become weight stable at about 18 months after their gastric bypass procedure and it s at about that time that I think it s appropriate to consider one of the body recontouring procedures like the abdominoplasty that we re performing today. What has your experience been, John?

5 00:14:26:00 I agree with you. I find about 16 months, months after the procedure, the rate of weight loss plateaus, levels out, and any time after that is a very good time to consider these operations. So, let s just talk about the stage we are now. As you can see, we have gone ahead and plicated the muscles underneath the belly. This is the belly button, which we re going to reposition as part of this operation. You can see how more taut the abdomen is and that is a necessary and useful part of this operation. Now what we re going to do is we re going to proceed and resect this excess skin and proceed with the closure. This hole here represents where the belly button used to be and we re going to reposition, create a new belly button for this patient and rejuvenate the belly button as well. 00:15:49:00 Now, I d like to mention that this is what we would term a standard abdominoplasty. The needs of this patient warrant this operation as a better choice operation. The markings that you saw earlier for the patient was not a standard abdominoplasty, it was a fleur-de-lis abdominoplasty and this is an important point. Not everybody gets the same operation. Everybody has different needs and we modify what we do to the best needs of the patients. Jim, what has been your experience? 00:16:30:00 Well, I agree. I think that my typical experience with the post-bariatric patient has been that there is some musculofascial weakness to the abdominal wall and in nearly every case with the exception of, I think, one patient, I ve had to perform plication of the abdominal wall. I think a more limited type of abdominoplasty in this subset of patients who need body recontouring as a result of massive weight loss, they really don t apply. 00:17:20:00 Certainly, so at the beginning of this operation, what you saw was me performing some markings. This was a prior patient of ours who has done very well and we have an interview for you to see where this patient goes through some of the things he experienced, not only in the physical sense but in a psychological sense. If we can please introduce the patient video? STEPHEN McRIGHT, PATIENT 00:17:52:00 It has taken some wear and tear off of my body and off of hers as well. Combined, we ve lost over 300 pounds. That s going to alleviate a lot of health problems. I was diabetic before I had my surgery. About six weeks out I was allowed to discontinue all of my medication so I m just like anybody else now. If I have a headache, I can t take ibuprofen because that s bad for my stomach, but I m just like a normal person now, I don t have the diabetes and I don t have high blood pressure. It s just opened up a whole new world. Doors will continue to open because of it. You know, first impressions are so important and in the last 18 years, people saw this fat guy walk in. Now they don t see that. For those that don t know me, it s really not a concern of theirs. The most fun that

6 we ve had with the whole thing is people that I ve known for years haven t seen me in several months, and to walk up and just start talking to them and ask them about their family and their kids and they re scratching their head, like, Who is this guy? And then, Oh, by the way, I m Stephen. And it kind of embarrasses them but it s been fun. That s the fun part. Given the results, I d do it all again tomorrow. We ve just entrusted ourselves to the great physician and he has blessed us immensely. Neither one of us had any complications from either procedure. No complications from my cosmetic surgery. It s just been wonderful. I d do it again tomorrow. 00:20:05:00 Would you like for me to read some more of these questions? 00:20:12:00 Yeah. 00:20:16:00 Well I think it s important to recognize that there is more than just a change in the physical appearance of the patients afterwards. Typically I ve seen them come in feeling and behaving more confidently, clearly having had a psychological benefit from the procedure as well. I think this patient demonstrates that well. I have been receiving a number of questions throughout the procedure and I d like to comment about a few of these. A lot of the questions are similar in nature, in particular, patients asking what the recovery time is. I d just like to remark on my experience and don t want to state that this experience may be typical for any other surgeon. Of course the time of recovery depends upon the operation that s performed and certain patient factors, the degree of lipodystrophy and (inaudible) of the excess skin, how much muscular tightening needs to be performed and those kinds of things. Typically, though, in my patients I notice that I m able to get them back into some light exercise by the end of six weeks after the operation. John, what s your timetable for getting folks back to a light level of exercise? 00:21:47:00 I agree with you, Jim. I like to wait about six weeks, particularly in cases like this, as you can see today, where we tighten the muscles of the abdomen. That is also a good time to complete the major part of the healing in this patient. But I think it s important to say that most of these patients, despite the fact that these are very big operations, with the right care, that we give them here, they stay with us for about a day or two. We get them up and walking from the same afternoon as the day of surgery and in general we ve had a pretty good success with fast recovery and I think that is important. In general, I tell people that they need to take about a week off, perhaps together with the weekends because a lot of people like to plan, particularly as it pertains to their work. I find that that is a good average? How about you, Jim?

7 00:23:03:00 No, I think that s right. In exceptional patients who are in quite good health and were active before, I will sometimes allow them back to light exercise as early as four weeks, but I d say more typically six weeks in my experience. Now, John, can you one of the other questions submitted by one of our viewers is: how much skin do we plan on removing? Then their follow-up to that was: how normal will the patient look afterwards? I think right now we can see that you re removing quite a significant amount of skin. 00:23:45:00 Yeah, we re going to be able to show it in just a second. In general, this is not our guiding factor, how much skin per se. I think that the main thing is, as much as we need to do this in a safe and effective way if we can put skin here you can see that it is a fair amount of skin but it can be greater than that or it can be less than that. The important thing to convey is that the actual amount is not what guides this operation, nor is the actual weight. This is not a weight-reduction operation; this is an operation to take care of the body contour and also the associated medical problems with that. 00:24:44:00 Yeah, I think that s an excellent point and one of the most common misconceptions of patients is that somehow this operation is adjunct to their bariatric surgery in terms of weight reduction. But really that s not the case. Instead what we re trying to accomplish here is restoration of the normal form that this patient should have without having had this problem of excessive weight on the lower abdomen. And with the weight loss, then, correcting the excess skin so that they ll have a more normal contour. Part and parcel of all that, I think, is abdominal wall plication. The amount of skin and the weight lost from the resection specimen is of little import although I know that, from my experience, my patients are quite concerned about this. One of my jobs as a surgeon is to discuss with them how this is really the wrong view and instead we re going to concern ourselves with giving them the best abdominal contour that we possibly can and getting them back to looking as normal as we can. So I think that s worthwhile to address and I find that to be one of the most common questions asked by my patients. How about you, John? 00:26:07:00 I agree with all these things you said. I think at this point, we may present the PowerPoint presentation that we have for our viewers, where we go over some of the indications of the operation and the common reasons and why we do this and what the patient and the surgeon goals are with that. So if we can have the PowerPoint presentation, please.

8 00:27:10:00 So what we re doing here, we are done with the resection. We re just washing out the wounds to cleanse the wounds with bacteriostatic solution and now we re going to check for bleeding. After we check for bleeding we are ready to proceed with the closure of this big wound. We re approaching the end of this operation and we ll be able to see how the final result will be in just a few minutes. Yes, so, what you re seeing right now is a presentation where we like to show you a few things about this operation. Bariatric patient, it s a Greek term, it relates to weight and the problems with a weight. This is a patient who had gastric bypass and you can see the more massive abdominal rolls present there. Like we talked about, patients can lose anywhere from 100 to 200 pounds and that s typically over a period of 14 to 16 months. This is another patient, actually, this is the patient that we saw in the interview, in the patient interview earlier. The goals for this operation are the same between the doctor and the patient. We try to change the physical self to help the patient with activities of daily living: with finding proper clothes, with exercise and to improve the overall quality in life. This also has to do with the ability to improve the psychological state, to help people become more active, to improve their self-esteem and to improve overall quality of life. In the next slide, you will see that the typical problems with gastric bypass focus on five areas: the face and the neck, the arms, the inner thighs, the breasts, the abdomen and the trunk. Okay. 00:30:03:00 We have another set of interesting questions here. Looks like a question from another plastic surgeon who asks if we find pardon me? It seems that he was wondering if you find leaving a thin carpet of fat on the fascia when undermining the abdomen reduces the incidence of postoperative seromas, or fluid collections, for those non-medical personnel. What do you find? 00:30:30:00 Well, you know, when you go down to the fascia and you create such a big space, that is one of the potential problems, seromas, with this operation, despite the fact that we ll adequately drain it. However, it is necessary sometimes to perform this operation. Now in some other patients where we can combine incision with liposuction, we don t undermine like the patient that we saw in the interview earlier. That is certainly a favorable approach. What do you think, Jim? 00:31:10:00 Yeah, I agree. I find that leaving that tissue down does act to help prevent the problem of seromas postoperatively. That s been my experience. Here s a question from a patient asking whether an abdominoplasty can be done a second time if done several years later and they have accrued more excess skin. I think there s no question that they can have a second abdominoplasty operation. We oftentimes do that.

9 00:31:40:00 I agree with you, Jim. Not only can we do a second abdominoplasty, but we can do liposuction or a combination of those procedures. 00:31:54:00 Here s another interesting question from a patient indicating that she had previous liposuction done on her lower abdomen. She s wondering whether this will impact her ability to have an abdominoplasty in the future. She s concerned that the previous liposuctioning might cause problems with the abdominoplasty. And I think the answer to that is no and, in fact, it s not uncommon for us to combine both liposuction with abdominoplasty. There are certain techniques that we utilize to help minimize postoperative complications such as skin loss or devascularizing portions of the abdominal skin flap. Typically, though, after a period of time like the one that you re describing, patients are able to undergo additional procedures because the body over time rebuilds its vasculature and that becomes actually less a problem in a secondary procedure than it would have been at the initial procedure, something that we refer to as the surgical delay phenomenon. 00:32:58:00 So now that we ve managed to overcome the problems with the PowerPoint, would you like to comment some more about this patient? 00:33:08:00 We can move to the next slide, Jim. So this is an example of another patient as you can see, that lady developed significant sagginess of her breasts and also significant loose skin, excess skin, under her armpits and also under the arms. With the operations that we have today available we see that we can get some good results, improve the youthfulness of the breasts and, again, this is not only something that improves the body, the physical self, but also the psychology of our patients. 00:33:53:00 That s a fantastic result, I think. 00:34:00:00 So we talk about this, Jim, a little bit. Again, the indications for these particular operations, in my mind, have to do with the problems that these successive abdominal rolls cause. We mentioned most of these, but I also find that it puts a lot strain on the back, particularly the lower back and people already have problems with that. I have found that taking care of this and tightening also the muscles underneath helps a lot with back pain as well. Have you found that to be your experience?

10 00:34:42:00 I have. I have. I m a little reticent to guarantee any patient that they might have an improvement of their symptoms of back pain as a result of this operation but, adjunct to the procedure, I have noticed that a number of patients have been commenting how their lower back pain has been improved. 00:35:03:00 This set of pictures, I think, highlights another set of procedures that we sometimes consider in patients who have undergone massive weight loss, called the belt lipectomy. 00:35:19:00 Would you like to comment a little on that? We did mention that not everybody gets the same operation and what they get has to do with what their needs are. Sometimes these abdominal rolls can be really trunkal rolls that can extend to the sides and they can extend all the way to the back and to properly address those patients we really have to excise that circumferentially and completely and this is what those slides illustrate in that patient. 00:35:51:00 Here, really, the abdominoplasty excision on the front is extended around to the sides and also to the back which provides, really, a lower body lift, elevating the buttocks and providing better skin tone and position, of course, also eliminating some of the redundant skin on the lateral thighs and also improving excess skin on the back, the lateral portion of the flanks and then, again, the abdominal region that we re addressing today. So it really can be an excellent operation for a subset of patients who have undergone gastric bypass surgery. 00:36:32:00 Again, this slide is from another patient showing a different kind of operation that we talked about before. Jim, that s the fleur-de-lis operation. The interesting thing though, that I want to bring up with this operation, is that that patient had a subcostal scar on the right. This was a scar that we started from a previous open colisistectomy and in the older times those used to be done open. That sometimes can be a significant problem when you and me know, when we design these operations. But what I did there is I designed my excisions so as to totally excise that scar and create really healthy flaps but also at the same time taking care of this horizontal excess that those patients often have. 00:37:40:00 Yeah, I agree. When you re able to get rid of that scar altogether, that facilitates fewer postoperative complications and at the same time provides the patient with a better aesthetic outcome and I think this patient here is a perfect example of that.

11 Will you talk just a bit about what your goals are in designing the various operations that we do for post-bariatric patients. 00:38:11:00 I think that except for the fact to improve the contour and remove the skin that causes all these problems that these patients have, the goals really are to encourage a more healthy and more active lifestyle that not only will help physically but help these patients to promote a better life. Let s not forget that oftentimes gastric bypass patients suffer from diabetes, hypertension, heart problems, atherovascular disease and all these problems over time as a result of the weight loss and improvement in contour, those problems oftentimes go away and that is a remarkable change in health status. 00:39:08:00 Yeah, some of my patients are able to exercise. If those problems don t go away completely, they re usually greatly improved by the level of physical activity that the patients are able to engage in that they weren t able to before so I think that s absolutely true. 00:39:29:00 Jim, why don t you talk a little bit about the other slides, please. 00:39:32:00 Sure. Well, we just remarked briefly about prior scarring and use of the fleur-de-lis abdominoplasty. You can see this picture here shows right upper quadrant abdominal scar typically seen in patients who have had open colisistectomy performed in the past. When able, it s my preference and I think Dr. Anastasatos as well, to remove these scars with the resection specimen. It facilitates more aesthetic closure, eliminates scars and also postoperative complications like dysvascular skin flaps and things of that nature. Of course, we prefer, here, to attend to hernias at the time of abdominoplasty. I think that s something that we pretty much routinely do nowadays. It wasn t always that way, but when able, we prefer to do it at the same time. 00:40:35:00 So, Jim, if I can direct our audience s attention peroxide to what we ve done here. We might as well so let s go ahead and remove the yellow dressings, please. So, again, this patient before had a breast lift and a breast reduction and you can see the results. We have proceeded to close, temporarily, we close with staples now, but we are going to replace all our staples with sutures and here we like to use sutures that are absorbed that we don t have to remove. So we have addressed the excessive skin, we have tightened the abdomen, we have addressed the inside components of the abdominal wall, which are the muscles which need to be addressed. We re going to create a new

12 position for the new belly button and also at the same time, we have addressed the pubic skin laxity that pretty much every time men and women have and they re very bothered by this. So we have rejuvenated all these areas and now we re ready to proceed and close. 00:41:59:00 Yeah, it s been my experience also. One of the questions posed by one of the viewers about this prepubic skin laxity and fat tissue excess, I do think that s a problem that can and should be addressed during the abdominoplasty procedure and, as is shown here, you ve done that quite nicely. 00:42:28:00 Okay. 00:42:28:00 Sure. Well, if you don t mind, I ll remark on these slides that are in the PowerPoint. Here, you can see the fleur-de-lis-type abdominoplasty incision having been done and beneath and in the region of prior open gastric bypass surgery the patient has a rather significant abdominal hernia. As I said, we prefer to try to attend to this at the very same time that we do the abdominoplasty procedure. As with any surgical procedure, there are problems that can occur. Those include problems of hypertension, diabetes, those types of problems that go along with the patient s weight problems, which are sometimes eliminated or greatly improved by the bariatric procedure, but which can be oftentimes improved further with body contouring. One of the things that we will occasionally see in patients who have undergone gastric bypass surgery and it s a bit unique to this subset of patients, because they ve had a procedure whereby some of the contents that they eat are bypassing the normal absorptive regions of the bowel, they may have a slightly malnourished state and this malnourished state can lead to wound healing problems. There are certain things that we do beforehand to assess the likelihood whether or not this patient will have problems. Typically those will include body chemistries and looking at the patient s ability to synthesize protein normally. That group of patients that are synthesizing proteins normally, my fear of wound-healing complications goes down significantly. 00:44:20:00 I agree with that, Jim. I find that these patients, despite the fact that they ve lost so much weight, they re often protein-malnourished. That s what makes them at more risk for wound-healing problems and slower wound healing. That is something that we need to pay particular awareness to.

13 00:44:47:00 So as my experience in taking care of these patients has matured, that s something that I kind of routinely do now, where I ll check a protein synthesis profile and also want to look at how the patient is clotting. If those two values are normal or very near normal then my fears of wound-healing complications or postoperative bleeding complications goes down significantly. 00:45:22:00 We ve really touched on the many benefits of abdominoplasty including improvement in body contour, improvement in skin tone. The potential improvement in lower back pain and improvement in body posture, elimination of that excess skin that can be a problem with skin infections, allows patients to exercise and further increase and improve the tone in their musculature and their overall body contour oftentimes inhibited by the excess skin that we removed during this operation. So it can really make a great impact on their ability to engage in physical activity. Not to mention clothes fitting better and the overall psychological impact that can be derived from this operation and other subset of patients who are interested in abdominoplasty. 00:46:20:00 Here s some more photographs. Is this, John, a photograph of the gentleman 00:46:25:00 Yep. This is the first patient that we saw, also the patient that was interviewed. The picture on the left is how he looked before and the picture on the right, that is only about 3 weeks after the operation. Despite the fact that it s so soon, you can tell that there is a significant improvement with his body contour. The next picture, the next slide is the side view of the same patient and we did mention about the fact that we rejuvenate the pubic area. You can see that in his case. Whether you are a male or a female, this is something that I find that patients are concerned about. 00:47:20:00 I agree. And, in fact, in a number of my patients, that s their #1 concern. Here s more before and after photographs. 00:47:30:00 That s another patient, that is that lady that also had that scar from the open colisistectomy that we removed. She s about three months out and you can see that the midline scar, although one may think it may be concerning to some, it does heal fairly well and I have found that my patients are not concerned really about that. When I mention that as a possibility, I did mention it to this lady, for instance, and they don t seem to care to have an extra scar as long as the outcome is the desired one. 00:48:16:00 I agree and I think this lady represents a wonderful result. You can see that the improvement in the contour of her flanks is quite significant. This is that same patient

14 on lateral view, only further emphasizing what a remarkable change the abdominoplasty procedure has made. Oh! 00:48:44:00 This is a personality well-known to all of us. By this I want to show that this is something that affects everybody. A lot of people have these operations. I think peoples awareness has increased over the past few years. Obesity has become such a tremendous problem in our country. My experience is that these operations do wonders for our patients, physically and emotionally and they promote a healthier lifestyle forever. Do you find that to be your case, your experience as well? 00:49:31:00 I do. I do. It s really amazing. I think the physical outcomes are overshadowed oftentimes by the psychological benefits that I ve seen, with patients moving from sort of a depressed mood into an elated mood. They come in to tell me about the many activities that they have planned that in reality they never would have considered before the operation. And just the overall impact on their life goes far beyond, I ve found, just the change in physical appearance. 00:50:10:00 You may want to look on the side. 00:50:19:00 For those of you who are watching the program to obtain continuing medical education credit, now would be the time for you to access that site. In the meantime and while you re doing that, I would like to address more questions sent in by our viewers. This comes from a gentleman who s interested in what the average time of this procedure is. 00:50:46:00 Well, the average time varies with the actual requirements. Some of the operations that we saw in the slides tend to be lengthier operations. Sometimes if we have to deal with other problems like the presence of hernias, that adds to the operative time. But, for example, in this lady, we ve been here for about 3 ½ hours now. We did the breast operations in two hours and we re beginning to close the abdomen. Just to clarify what we re doing here. We close temporarily with staples so we can see the alignment that we want and then we replace all our staples with sutures that are absorbable and we don t have to remove.

15 00:51:40:00 Another question comes from a plastic surgery resident who indicates: since we ve already performed a breast lift, how much time has passed since then and what special considerations did you make keeping in mind that an abdominoplasty was to follow? 00:52:01:00 I didn t hear the question, Jim. 00:52:02:00 Oh, I m sorry. Did you make any special were there any special considerations in doing the breast lift given that you planned to follow with an abdominoplasty? 00:52:14:00 Sometimes when we do breast lifts and reduction operations, you know, particularly in large patients that me and you have to often deal with in the geographical locale where we are, sometimes I will do liposuction below the inframammary scar and in the flanks. In this particular case, this is not something I would do because I want to make sure that I m conservative when it comes to the blood supply which comes in from the intercostal vessels to preserve and support this skin. So that would be the consideration that I did. 00:52:54:00 Here s a question from a lady who s viewing the webcast indicating her concern about the possibility of stretch marks in this patient now that we have stretched her abdominal skin. 00:53:08:00 This is one of the benefits of doing this operation. Unfortunately there s no good technique to take away stretch marks or make them disappear except for cutting them out. So this lady had a lot of stretch marks which was removed and now there re going to be less. This operation does not create stretch marks, it just makes them go away. 00:53:36:00 I d just like to reaffirm what Dr. Anastasatos has said. In reality, the stretch marks are a by-product of the weight that the patient had prior to gastric bypass surgery. I ve found pretty much uniformly in my patients who have undergone abdominoplasty, after significant weight loss from bariatric surgery, and other patients who have not had bariatric surgery, but who have had a significant weight loss. Mostly those stretch marks

16 accrue on the lower abdomen and as a result of our taking lower abdominal skin in this procedure, we re actually able to remove many of the stretch marks. Not always all of them, but we try to remove as many as we can and sometimes all of them, if we can. My experience in following these patients post-operatively is that new stretch marks don t accrue as a result of having stretched the skin. This thicker dermis skin that we move from the upper abdomen down to the lower abdomen seems to be fairly resilient. 00:54:41:00 Another question here from one of the viewers asks: why is it that we are able to remove that much skin and fat on a patient that has gone through gastric bypass but not in patients who have not had gastric bypass procedures done? Would you like to comment on that, John? Or I m happy to, if you d like. 00:55:02:00 Please do. 00:55:03:00 Well, the answer is, quite simply, every patient is a little bit different. Some patients who have never had gastric bypass done who can have as much skin and fat removed. There are some who have less skin excess, less abdominal fat tissue excess and really those patients don t make good candidates because they don t have that much skin to offer as a donor for removal. Oftentimes on gastric bypass patients, though, because of the incredible weight loss and excess skin, we are able to remove more than we would typically do in an abdominoplasty that s done purely for strictly cosmetic purposes. 00:55:51:00 What I did here is, with the help of these sutures that help me mark the midline, I m making a new hole for the new belly button position. Like I said, one of the things we do for this operation is reposition the belly button and we create a new belly button, we rejuvenate it, if I may use that term. So the marking that I did for the belly button was a rhomboid, a rectangular, almost, marking, but it will result in a new circle and we re going to place the belly button underneath into that circle. 00:56:41:00 Here s an interesting question from a patient wondering would she be able to have her belly button pierced after this repositioning? 00:56:51:00 Yes, she may.

17 00:56:54:00 That s been my experience also. The vascularity to the underlying (inaudible) 00:57:03:00 Yes, people can pierce their belly buttons afterwards. There s no contraindication to doing that. Any other questions from the audience? 00:57:18:00 We do. We have a question from a physician who s watching. He asks about how much tissue do you (inaudible) 00:57:34:00 I close the wounds in two layers, a deep dermal layer and then a subcuticular. Certainly. So, again, we re going to bring out the new belly button from here. 00:58:10:00 John, do you like to do any contouring of the do you have any preferred techniques for contouring the abdominal skin for insetting umbilicus? 00:58:28:00 It depends, again, on a lot of factors. How stretched out it is. Sometimes we plicate the belly button to the fascia underneath so we can give it a more inwards-looking view. Sometimes we don t do that. Sometimes it s important to know what the patients want. Oftentimes they don t care, but sometimes they re very particular about their belly button appears. It s important to take that into consideration. So what you see here now is we re insetting this belly button. We re going to proceed to close this wound and this hole that the belly button pre-existed, we re just going to close it into a straight line. So, let me proceed and thank our viewers and our audience for being here with us today for this limited period of time. We re most appreciative that you watched what we did. We appreciate all your questions and your input. 00:59:57:00 And I d like to thank you for joining us today here at UAB for a look at an abdominoplasty having been performed on a post-bariatric patient. This is Dr. James Long thanking you for Dr. John Anastasatos and we look forward to hearing from you. NARRATOR

18 01:00:20:00 This has been an abdominoplasty performed at UAB Hospital at the University of Alabama at Birmingham in Birmingham, Alabama. The presentation is a continuing medical education program. For those viewers who registered for CME, click on the slide in the window to your right to take the post-test. To obtain more information or make an appointment or make a referral, please click on the buttons on your screen.

19

20