Correlation of Complications of Body Contouring Surgery With Increasing Body Mass Index The latest statistics from the National Center for Health Statistics state that 30% of U.S. adults over the age of 20 years more than 60 million people are obese. Sixteen percent, or over 9 million, of young people between 6 and 19 years of age are considered overweight. 1 The rise in prevalence of obesity and Drs. Au, Hazard, Boustred, and Mackay are from the Division of Plastic and Reconstructive Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA. Ms. Dyer is from the Department of Public Health Services at the same institution. Dr. Miraliakbari is from the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA. Katherine Au, MD; S. William Hazard, III, MD; Anne-Marie Dyer, MS; A. Mark Boustred, MD; Donald R. Mackay, MD; and Reza Miraliakbari, MD Background: There have been conflicting reports regarding the incidence of postoperative complications in body contouring procedures in obese and morbidly obese patients. Our subjective impression has been that the complication rate is significantly higher for these patients than it is for other weight groups. Objective: The purpose of our study was to conduct a retrospective chart review to delineate our institution s complication rate in body contouring operations across all weight groups and to identify predictors of poor outcomes/complications that would help guide patient selection. Methods: The records of 129 patients who underwent a single body contouring procedure at The Penn State Hershey Medical Center from 1993 to 2002 were reviewed. Patients were categorized based on their body mass index into the following weight groups: ideal, overweight, obese, morbidly obese, and severely morbidly obese. The complications were grouped into minor, major, or combined (minor or major). Patients who underwent combined procedures were excluded from the study. Results: There was a statistically significant association between minor (P =.0006), major (P =.0098), and combined (P <.0001) complications and weight group. More specifically, the percentage of complications increased as weight category increased. The percentage of minor complications increased from 3.3% in the ideal weight group to 46.9% in the severely morbidly obese group. Similarly, the percentage of major complications increased from 6.6% in the ideal weight group to 43.7% in the severely morbidly obese group. Both major and minor complications saw the largest increase in complication rates between the morbidly obese and severely morbidly obese groups. Furthermore, those in the obese (odds ratio [OR] = 6.43; P =.0115), morbidly obese (OR = 5.54; P =.0237), and severely morbidly obese (OR = 19.80; P <.0001) weight groups were more likely to experience minor or major complications than those in the ideal weight group. Conclusions: This study demonstrates two points: (1) it confirms that there is a significant increase in the occurrence of complications among morbidly obese and severely morbidly obese patients undergoing a single body contouring procedure, and (2) it shows there is an increase in the occurrence of complications with worsening degree of obesity. The (post weight loss) body mass index at the time of body contouring surgery is a predictor for postoperative complications. (Aesthetic Surg J 2008;28:425 429.) surgical weight loss options has led many patients to seek plastic surgery to correct their unsightly loose skin folds and stretch marks. While massive weight loss (MWL) improves health and quality of life, the sequelae of symptomatic skin redundancy, especially in the arms, breast, abdomen, and thighs, can benefit from body contouring. The American Society for Bariatric Surgery projected that more than 144,000 patients had bariatric surgery in 2004, compared with 103,000 in 2003. According to The American Society of Plastic Surgeons (ASPS), more than 106,000 post-bariatric body contouring procedures were performed in the United States in 2004. This number reflects a 45% to 72% increase in Aesthetic Surgery Journal Volume 28 Number 4 July/August 2008 425
Table 1. Obesity classification and breakdown of patient enrollment by BMI BMI Categorization Patients % <25 Ideal (includes underweight) 30 23.26 25 30 Overweight 22 17.05 31 35 Obesity (class I) 24 18.60 36 40 Morbid obesity (class II) 21 16.28 >40 Severe morbid obesity (class III) 32 24.81 procedures such as thigh, buttock, or upper arm lifts ( 75% were performed after MWL). 2 With an increasing number of patients seeking post-bariatric cosmetic surgery, appropriate preoperative assessment and selection of the appropriate timing for surgery is essential. The importance of this initial assessment is evident by the attention dedicated to it in the recent literature. 3 5 In light of increased demand for body contouring procedures after MWL, plastic surgeons naturally look for predictors of poor outcomes/complications to help guide their patient selection. Obesity serves as an independent risk factor when considering operative procedures. The poor outcomes attributable to patient obesity and secondary effects such as hypertension, diabetes, sleep apnea, cardiovascular disease, and poor healing have long been recognized. 4 Degrees of obesity are defined by the body mass index (BMI), which is obtained by dividing the weight in kilograms by the height in meters squared (kg/m 2 ). BMI is a concise, objective, easy mathematical calculation that helps us to determine perioperative risk in patients who want surgery. 6 The clinical definition of obesity is a BMI of more than 30 kg/m 2 ; morbid obesity (MO) is a BMI of more than 35 kg/m 2, and severe morbid obesity (SMO) is a BMI of more than 40 kg/m 2 (Table 1). 7 A number of studies have shown that there is an increased surgical risk in obese patients that is correlated with an increased BMI, without further identifying a specific BMI over which there was a significant increase in complications. The patients identified in these studies experienced an increased incidence of wound complications, pulmonary complications, thromboembolic events, and mortality. 6,8 Vastine et al. 9 performed a retrospective review examining the wound complications of abdominoplasty in 90 obese patients. Patients were divided into three groups (obese, borderline, and nonobese) based on the degree of weight above ideal body weight. The results indicated that 80% of obese patients had complications compared with borderline and nonobese patients who had complication rates of 33% and 32.5%, respectively. 9 Matory et al. 10 performed panniculectomies in a group of 42 obese individuals weighing more than 220% over their ideal body weights. Their results revealed a 68% complication rate which was related primarily to pulmonary function and wound breakdown/ infection. 10 Tillmans et al. 11 evaluated complication rates of patients undergoing panniculectomy at the same time as gynecologic surgery. They found that the rate of wound complications increased with increasing BMI. 11 Acarturk et al. 12 reported that patients who had panniculectomies simultaneously with bariatric surgery had more complications than patients who underwent panniculectomies after bariatric surgery. More recent studies reported in the last few years have reported lower complications without BMI stratification. 4,13 16 The overwhelming conclusion from these reviews is that increasing BMI is associated with an increased number of complications and poorer outcomes. Although many studies have addressed the differing techniques of body contouring surgery after MWL, few have looked at complication occurrence and its relationship with increasing BMI. In this paper, we performed a retrospective review of 129 patients to evaluate the effect of increasing BMI on occurrence of complications at our institution. METHODS A retrospective, random chart review was performed on patients who underwent body contouring surgery at Penn State Milton S. Hershey Medical Center from 1993 to 2002. Age, gender, and BMI were obtained. BMI was used to determine the patient s weight group with groups defined as ideal (I), overweight (OW), obese (O), morbidly obese (MO), and severely morbidly obese (SMO). The occurrence of complications was also obtained from both hospital and outpatient charts. Complications were recorded into minor or major categories. Minor complications included postoperative wound infection, seroma, and hematoma. Major complications included any wound or dehiscence requiring dressing changes, need for hospital readmission or prolonged admission, need for re-operation, or death. The Pearson and Mantel Haenszel 2 tests were used to test for an association between complication occurrence and weight group. To further quantify this association, three logistic regression models were run to predict minor, major, or minor or major complications with weight group as the only predictor. Following these calculations, patients who received lipoplasty, rhytidectomy, and blepharoplasty were then removed and 2 tests and logistic regression models were repeated. All analyses were performed using SAS software for Windows (version 9.1; SAS Institute Inc., Cary, NC). RESULTS A total of 139 patient charts were reviewed. Ten patients underwent more than one surgical procedure, and were therefore excluded from the study, resulting in a final sample of 129 patients. Surgical procedures included abdominoplasty, reduction mammoplasty, brachioplasty, thighplasty, flankplasty, mastopexy, rhytidectomy, blepharoplasty, and lipoplasty. There were 8 men and 121 women, and 75% of the patients were between the ages 426 Volume 28 Number 4 July/August 2008 Aesthetic Surgery Journal
Table 2. Distribution by procedure group and BMI Morbidly Severely Procedure group Ideal Overweight Obese obese morbidly obese Total Abdominoplasty 14 (46.7) 5 (22.7) 8 (33.3) 4 (19.1) 18 (56.3) 49 Reduction mammoplasty 3 (10.0) 12 (54.6) 12 (50.0) 14 (66.7) 11 (34.4) 52 Brachia/thigh/ flankplasty/mastopexy 0 (0.0) 2 (9.1) 3 (12.5) 2 (9.5) 2 (6.3) 9 Lipoplasty 7 (23.3) 3 (13.6) 1 (4.2) 1 (4.8) 1 (3.1) 13 Head and neck 6 (20.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 6 Total 30 22 24 21 32 129 Table 3. Presence and type of major complications Major complications n (%) Significant wound 19 (14.7) Dehiscence 3 (2.3) Readmission 4 (3) Re-operation 5 (4) Tissue necrosis 3 (2.3) Death 1 (0.8) Table 4. Presence and type of minor complications Minor complications n (%) Infection 19 (14.7) Seroma/hematoma 8 (6.2) Minor wound 1 (0.8) of 32 and 55 years. Thirty-three patients had previously undergone gastric bypass surgery, while the remaining lost weight through diet and exercise. The distribution of procedures performed as well as the distribution of procedures by weight group can be found in Table 2. Tables 3 and 4 demonstrate the distribution of minor, major, and combined complications by weight group. There was a statistically significant association between minor (P.0006), major (P.0098), and combined (P.0001) complications and weight group. More specifically, the percentage of complications increased as weight category increased; this trend was statistically significant for minor (P.0002), major (P.0003), and combined (P.0001) complications (Table 5). To further evaluate the significance of this association, all patients who received lipoplasty, rhytidectomy, or blepharoplasty were removed, and a statistically significant association between minor (P.0135) and combined (P.0102) complications and weight group remained. The percentage of complications increased as weight category increased for minor (P.0043), major (P.0053), and combined (P.0007) complications, with the above mentioned procedure groups removed (Table 7). The percentage of minor complications increased from 3.3% in the I (ideal) weight group to 46.9% in the SMO group, with the largest increase being between the MO and SMO groups (14.3% to 46.9%). Similarly, the percentage of major complications increased from 6.6% in the I weight group to 43.7% in the SMO group, with the largest increase being between the MO and SMO groups (28.6% to 43.7%). When major and minor complications were grouped together, the trend was similar, increasing from 10.0% in the I weight group to 68.7% in the SMO group, with the largest increase being between the MO and SMO groups (38.1% to 68.7%). Odds ratios from the logistic regression models predicting occurrence of minor, major, and minor or major complications can be found in Table 6. Odds ratios from the logistic regression models with lipoplasty, rhytidectomy, or blepharoplasty groups removed are represented in Table 8. The results indicate those in the SMO group are 25.6 times more likely to experience minor complications that those in the I weight group (P.0026). When patients receiving lipoplasty, rhytidectomy, or blepharoplasty were removed, those in the SMO group were 13.2 times more likely to experience a minor complication (P.0182). Likewise, those in the MO weight group and SMO group are 5.6 and 10.9 times more likely to experience a major complication than those in the I weight group (P.0495 and P.0034, respectively). Repeating the logistic regression models with lipoplasty, rhytidectomy, and blepharoplasty patients removed, those in the SMO group were 6.175 times more likely to experience a major complication (P.0292). Finally, those in the O, MO, and SMO groups are 6.4, 5.5, and 19.8 times more likely, respectively, to experience a minor or major complication than those in the ideal weight group (P.0115, P.0237, and P.0001, respectively). With patients receiving lipoplasty, rhytidectomy, or blepharoplasty removed, those in the SMO group were 9.8 times more likely to experience a minor or major complication (P.021). BMI and Body Contouring Complications Volume 28 Number 4 July/August 2008 427
Table 5. Minor, major, or combined complications by BMI with 2 P Complication Ideal Overweight Obese Morbidly obese Severely morbidly obese Pearson Mantel-Haenszel Minor 1 (3.3) 4 (18.2) 4 (16.7) 3 (14.3) 15 (46.9).0006.0002 Major 2 (6.7) 3 (13.6) 6 (25.0) 6 (28.6) 14 (43.8).0098.0003 Combined 3 (10.0) 6 (27.3) 10 (41.7) 8 (38.1) 22 (68.7) <.0001 <.0001 Table 6. Odds ratio for minor, major, or combined complications by BMI Minor, OR (95% CI) Major, OR (95% CI) Combined, OR (9% CI) Overweight 6.44 (0.67 62.31) 2.21 (0.34 14.51) 5.538 (1.26 24.40) Obese 5.80 (0.60 55.81) 4.67 (0.85 25.71) 6.429 (1.52 27.21) Morbidly obese 4.83 (0.466 50.09) 5.60 (1.00 31.24) 5.538 (1.26 24.40) Severely morbidly obese 25.59 (3.10 211.25) 10.89 (2.21 53.69) 19.800 (4.85 80.91) Table 7. Minor, major, or combined complications by BMI with 2 with lipoplasty, rhytidectomy, and blepharoplasty groups removed P Complication Ideal Overweight Obese Morbidly obese Severely morbidly obese Pearson Mantel-Haenszel Minor 1 (5.88) 4 (21.05) 4 (17.39) 3 (15.00) 14 (45.16).0135.0043 Major 2 (11.76) 3 (15.79) 6 (26.09) 6 (30.00) 14 (45.16).0844.0053 Combined 3 (17.65) 6 (31.58) 10 (43.48) 8 (40.00) 21 (67.74).0102.0007 Table 8. Odds ratio for minor, major or combined complications by BMI with lipoplasty, rhytidectomy and blepharoplasty groups removed Minor, OR (95% CI) Major, OR (95% CI) Combined, OR (9% CI) Overweight 4.27 (0.427 42.63) 1.41 (0.21 9.62) 2.15 (0.44 10.44) Obese 3.37 (0.34 33.26) 2.64 (0.46 15.14) 3.59 (0.81 16.00) Morbidly obese 2.82 (0.266 30.02) 3.21 (0.55 18.64) 3.11 (0.67 14.43) Severely morbidly obese 13.18 (1.55 112.05) 6.18 (1.20 31.71) 9.80 (2.28 42.06) DISCUSSION The number of MWL patients has grown as the popularity of obesity surgery has increased over the past several years, leading to more patients seeking body contouring procedures. The ongoing metabolic changes after significant weight loss, nutritional challenges, psychological effects of bariatric surgery, and likely persistent secondary effects of obesity (diabetes, cardiovascular disease, and pulmonary disease) can make these patients poor surgical candidates. As plastic surgeons, the onus is upon us to recognize the risk factors for poor outcomes and higher complication rates. By following some of the recently stated guidelines, this task has become less daunting. 4,5 Many authors have used elevated BMI as an indicator of significant risk factors. 17 We have implemented the outcome of this study into our present practice. We offer body contouring to MWL patients with BMIs lower than or equal to 30. The group with a BMI between 31 and 32 is offered close follow-up with referral to a nutritionist along with being encouraged to develop an active exercise routine. The group with a BMI of more than 32 receives operations only when medically necessary. Indications include skin infections, recurrent severe intertrigo, significant func- 428 Volume 28 Number 4 July/August 2008 Aesthetic Surgery Journal
tional problems caused by excess skin, or massive hernias. In accordance with the recent recommendations, all the patients referred for body contouring undergo medical, nutritional, social, and psychological screening. In the near future, we hope to tabulate and publish our outcomes based on our new patient selection process and further delineate whether there are differences in complication rates between surgical and nonsurgical weight loss groups. CONCLUSION MWL achieved by either bariatric surgery or diet and exercise can greatly improve both the physical and mental health of patients. However, the physical limitations most often introduced by the excess skin adversely affect their quality of life. A persistently poor body image despite the patient s enormous accomplishment with successful weight loss remains a significant issue. Body contouring procedures, in a properly selected group, can be immeasurably rewarding to the patient as well as the plastic surgeon. In this study, we have shown that increasing BMI in MWL patients is associated with increased occurrence of complications after body contouring procedures. It is our impression that BMI can be used, in conjunction with other clinical factors, as an effective means of identifying patients with an elevated risk of postoperative complications. DISCLOSURES The authors have no disclosures with respect to the contents of this article. REFERENCES 1. Centers for Disease Control and Prevention. Overweight and obesity. (Accessed 1/27/2006, at http://www.cdc.gov/nccdphp/dnpa/obesity/ index.htm.) 2. American Society of Plastic Surgeons. (Accessed 1/27/2006, at http://www.plasticsurgery.org/media/statistics/index.ctm) 3. Barone CM, Okoro SA, Deowall C-C, Helling ER. Outpatient extended abdominoplasty in the patient with massive weight loss. Aesthetic Surg J 2007;27:129 136 4. Kenkel J, ed. Body contouring after massive weight loss. Plast Reconstr Surg 2006;117(Suppl 1):1S 86S. Theme issue. 5. Rubin JP, Nguyen V, Schwentker, A. Perioperative management of the post-gastric bypass patient presenting for body contouring surgery. Clin Plast Surg 2004;31:601 610. 6. De Jong RH. Body mass index: Risk predictor for cosmetic day surgery. Plast Reconstr Surg 2001;108:556 561. 7. American Society for Bariatric Surgery. (Accessed 1/27/2006, at http://www.asbs.org/html/bmi.htm.) 8. Simon S, Thaller SR, Nathan N. Abdominoplasty combined with additional surgery: A safety issue. Aesthetic Surg J 2006;26:413 416. 9. Vastine VL, Morgan RF, Williams GS, Gampper TJ, Drake DB, Knox LK, et al. Wound complications of abdominoplasty in obese patients. Ann Plast Surg 1999;42:34 39. 10. Matory Jr WE, O Sullivan J, Fudem G, Dunn R. Abdominal surgery in patients with severe morbid obesity. Plast Reconstr Surg 1994;7:976 987. 11. Tillmanns TD, Kamelle SA, Abudayyeh I, McMeekin SD, Gold MA, Korkos TG, et al. Panniculectomy with simultaneous gynecologic oncology surgery. Gynecol Oncol 2001;83:518 522. 12. Acarturk TO, Wachtman G, Heil B, Landecker A, Courcoulas AP, Manders EK. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg 2004;53:360 367. 13. Persichetti P, Simone P, Scuderi N. Anchor-line abdominoplasty: A comprehensive approach to abdominal wall reconstruction and body contouring. Plast Reconstr Surg 2005;116:289 294. 14. Pollock H, Pollock T. Progressive tension sutures: A technique to reduce local complications in abdominoplasty. Plast Reconstr Surg 2000;105:2583 2586. 15. Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau P, Mimoun M. Abdominal dermolipectomies: Early postoperative complications and long-term unfavorable results. Plast Reconstr Surg 2000;106:1619 1623. 16. Aly AS, Cram AE, Chao M, Pang J, McKeon M. Lipectomy for circumferential truncal excess: The University of Iowa experience. Plast Reconstr Surg 2003;111:398 413. 17. Williams TC, Hardaway M, Attuna B. Ambulatory abdominoplasty tailored to patients with an appropriate body mass index. Aesthetic Surg J 2005;25:132 137. 18. Taylor J, Shermak M. Body contouring following massive weight loss. Obes Surg 2004;14:1080 1085. Accepted for publication November 28, 2007. Reprint requests: Donald R. Mackay, MD, Professor and Chief, Penn State Milton S. Hershey Medical Center, Division of Plastic and Reconstructive Surgery, 500 University Dr. H071,Hershey, PA 17033. E-mail: dmackay@psu.edu. Copyright 2008 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$34.00 doi:10.1016/j.asj.2008.04.003 BMI and Body Contouring Complications Volume 28 Number 4 July/August 2008 429