Body Contouring - Weight Loss

Following significant weight loss after dieting or Bariatric Surgery the body subcutaneous fat and surrounding skin hangs in folds. This is uncomfortable and interferes with normal activity. It can also be embarrassing. The areas affected are similar in each patient – abdominal overhang, breasts and buttocks empty and droopy, inner thigh and inner arm excess, and back folds. The correction of these unwanted skin/fat folds involves staged procedures usually six months apart. Two or more operations are sometimes needed to optimize body shape. The operations remove excess skin, unwanted scars, stretch marks and fat. The procedures also lift and tighten loose tissues restoring a more normal body shape. The different procedures are tailored to your particular problem(s). It is important to have a stable weight, and be feeling well before undergoing any surgery.

Most patients wish to have the excess abdominal tissue removed first. These patients usually require a belt lipectomy which involves removal of tissue from around the lower trunk. This operation removes the overhanging belly, lifts the mons pubis, removes folds from the lower back and lifts the anterior/lateral thighs and buttocks. A belt lipectomy operation is performed under general anaesthesia and usually requires hospitalisation of 2-3 days. The operation starts with you in the prone position (facing down) and the excess tissue is removed from your lower back. While still asleep you are turned over so that I can perform the abdominoplasty component of the surgery on the front of your tummy. An incision is made from hip to hip connecting with the back incision, and around the belly button. A large wedge of skin and fat is excised from above the belly button to just above the pubic hair. Some areas may be treated with liposuction and the muscles above and below the belly button can be tightened. Although this operation does leave the biggest scar, it does provide the greatest degree of improvement in shape. Patients still planning pregnancies should wait until completion of their family before undergoing abdominal contouring surgery. The belt lipectomy or other suitable lower trunk procedure can be combined with other site surgery depending on your fitness. Subsequent operations involve lifting and filling empty breasts, arm and thigh lifts, and adjunctive liposuction. These can all be discussed with me when the time is right.

What can be expected at the initial consultation?

At the initial consultation you will be assessed as to whether you are a good candidate for surgery. Your entire body will be carefully examined to assess the skin quality, the quantity of fat and the muscle tone. Your general fitness for the procedure will be evaluated and the potential for problems sought. It is important to know about previous abdominal surgery, pregnancies, medication that you are on, previous leg or lung clots and whether or not you smoke. Your reasons for wanting the procedure will also be discussed. It is important that your expectations concerning the outcome of the procedure are realistic. If they are, you can expect to be happier with the result. When people lose a lot of weight it is in fact the entire skin envelope that changes and surgery cannot address everything. Addressing the areas that concern you the most is my priority. Once you have been fully assessed, an operative plan tailored to your individual needs will be formulated. The incision to be used, the amount of skin and fat to be excised, whether muscle tightening and navel repositioning is to be performed, and whether liposuction will be used as an adjunct will be discussed with you.

Do not be hesitant to ask questions, now or at any other time.

Medical aids or health insurance companies do not usually provide cover for this kind of surgery although occasionally a motivation can be done especially if you have lost large amounts of weight, or have a hernia.

Preparing for surgery

Ideally surgery is performed when you are fit and healthy. No special diet or exercise program is required. It is a good idea to have good fluid and protein intake for a few weeks before your operation. You should also clean the areas close to those undergoing surgery (the perineum, buttocks, umbilicus before a belt lipectomy for example).You should not have been on a long-haul flight for 2 weeks prior to surgery.

It is advisable to stop smoking at least six weeks prior to surgery and not to smoke until your wounds have healed - usually about six to eight weeks after the operation. It is well known that there is a higher frequency of complications in patients who smoke.

On the morning of surgery you should wash well. Do not shave your pubic hair specifically. Prior to surgery, the incision lines will be marked with a pen in your room. Ms Grob usually takes photographs for your records immediately before surgery.

The Surgery

Surgery will be performed in an operating theatre under general anaesthesia. You will need a urinary catheter to monitor fluid balance, and may need blood during or after the operation. A belt lipectomy takes between three to five hours depending on what will be done.
Following surgery the wounds are closed with dissolving sutures, and drains may well be left in place for a few days. Dressings and an elasticised garment will be applied.

What can be expected after the operation?

Following the operation you should be relatively pain free although you may feel some discomfort with movement. Post-operatively, you will be given strong painkillers if needed (such as opiates) and patient controlled analgesia (PCA) can be arranged for in-patients. With PCA you control the amount of painkiller that you receive - it is effective and safe.

You will be allowed to eat and drink once you are awake. As an in-patient, you will be well looked after in hospital and gentle mobilisation will be started as soon as you are awake. Immediately after surgery you should start with wiggling your toes and ankle and knee movements to help prevent leg clots. Avoid crossing your legs in bed. On the first post-operative day you should mobilise to a chair, walk to the bathroom and a little around your room. Daily showers are encouraged. Once the drains have dried up, they are removed and you can go home. Occasionally if the drains have not dried up, you will need to either stay another day or go home with the drain. This is easy to manage with some simple advice. Someone will need to drive you home and look after you. I advise that you have homecare for the first week to two, and that you have stocked up on all essentials before surgery. You will be given painkillers to take home with you. At home you should mobilize gently and rest frequently. On the first day back at home after surgery, you should try to get up into a comfortable chair and would be encouraged to walk around within the house. Following the first week of gentle mobilisation, you could get around a bit more – walks in the park and to the local shops are fine. After two weeks you can usually drive again.

How long does it take to get back to normal?

Healing is a variable process and it may take you a month or longer to feel like your old self again. People vary enormously in their recovery period. At home you need to take it easy but do not take to your bed. You will need help if you have small children for 2 weeks. Gradually increase your walking day by day. Do not drive until you really feel well – usually 2 weeks. Shower daily to stay clean. When discharged from hospital you will be provide with comfortable elasticated Tubigrip. If your Tubigrip becomes blood-stained, wash and dry it before reapplying it. After two weeks you will need to change to a more inconspicuous elasticated support garment. Ms Grob uses MACOM, a web based garment supply company – please order the relevant elasticated support garments before your operation. The wounds are sealed by 6-8 weeks, but the scars continue to mature for up to 18 months to 2 years, by which stage they should be thin, fine, inconspicuous lines.

Massage of the scars with an aqueous cream helps, but should only be started after 1 month. Bruising take about 2 - 3 weeks to settle. Although the improvement is immediately seen after surgery, swelling can take up to 12 months to settle fully. To help diminish swelling and bruising, abdominal support as described above should be worn for 6-8 weeks. Return to work is usually after one month to six weeks depending on your job. You will find that contrary to what you expect, your mood will be down following surgery and you may feel depressed, even tearful. You will also feel tired. This is a normal occurrence and as the swelling and bruising subside and your body heals, so your mood will elevate and improve. Mobilisation should be gentle, but begun early. Thereafter mobilisation should progress so that gentle exercises can be begun about one month after surgery. Return to work by a month and sport by 6 weeks is usual. Vigorous exercise should be avoided for six weeks, until you feel comfortable – your body will tell you if you are pushing it too hard.

It is advised that you are able to fly short haul 2 weeks after the operation and that you can fly long haul 4-6 weeks post-operatively.

What are the risks?

When performed by a qualified plastic surgeon, belt lipectomy is normally safe and the results predictable. Please be aware that all surgery has limitations – surgery on your lower trunk has less improvement on the upper trunk. A belt lipectomy is circumferential lower trunk surgery – the scar is above the buttocks on the lower back - the upper buttocks is much improved (but the lower buttocks less so). In the front, the scar lies above the mons pubis – the mons pubis is elevated (or reduced in size), the upper anterior and lateral thighs are lifted and tightened (but the inner thigh is not improved at all). The lower abdomen is tightened – but this needs to be done safely as removing too much tissue and closing the wounds too tightly risks the wounds opening up again. These are some of the limitations of the belt lipectomy – an improvement is expected, but a magical new tummy is not possible. Secondary liposuction or even a reverse abdominoplasty may be needed if the tissue laxity / hang is severe after weight loss.

All surgery carries risks and for lower trunk surgery the following may happen:

Bruising, Bleeding, Haematoma and Seroma: Bruising of the tissues is the norm and can be expected to last for 2-3 weeks after operation. Occasionally, after the operation, a vessel may start to bleed. This can result in a collection of blood (haematoma, <5%). The commonest time for this to occur is early after the operation and if the amount of blood is excessive, a small operation will be required to control the bleeding. Seroma refers to the accumulation of serous fluid (a pale straw coloured fluid) that leaks out from damaged capillaries and lymph vessels. Sometimes a seroma requires repeated drainage with a needle and syringe. This is usually relatively painless and is done in the outpatient rooms.

Infection, Wound Breakdown, Skin Necrosis: Infection is not uncommon (<2%) with belt lipectomies and can result in swelling, redness and tenderness at any time up to three weeks after surgery. This usually responds well to a course of antibiotics. Occasionally however, it can result in some opening of the wounds or loss of tissue (skin necrosis), especially low down, near the scar or of the belly button. This can occur as the operation interferes with the blood supply of the tissues. It is usually small and managed by regular wound dressings and heals in about 6-8 weeks.

Sensory problems and numbness below the belly button occurs in nearly all patients but is usually transient. Can take up to two years to resolve, and may not resolve completely.

Scarring - All patients will have scars and these must be expected after the operation. In the majority of patients by 18 months to 2 years after surgery the scars settle down to thin lines, which are soft and not very noticeable. If you have other scars on your body from previous surgery or trauma, these may give an indication as to the quality of scar you can expect. To minimise scarring, you will be expected to support the scars with tape for about 6 months after the operation. You will be advised as to how to do this. Massage and sun avoidance also help. Occasionally scars may become abnormally large, red, stretched and raised or even form a keloid, which may require further treatment.

Asymmetries, Irregularities in Contour and Dog-ears: Dog-ears are small folds of skin that occur at either end of the scar, caused by a natural folding of the skin when the wound is closed. Great care is taken during the operation to avoid producing dog-ears, but sometimes they cannot be avoided. Small dog-ears seen in the early postoperative period will eventually settle on their own in the first 6-9 months after surgery. If they do not settle after this time, they can be simply excised in a small operation under local anaesthetic to correct them.

General surgical complications such as deep vein thrombosis. This is a rare but serious complication of surgery and anaesthesia, where a blot clot forms in the veins, usually the legs and may migrate to the lungs (pulmonary embolism) interfering with their normal function resulting in possible life threatening consequences. Early mobilisation helps to minimise the risks of this. Deep breathing and coughing is encouraged immediately after surgery to help prevent lung problems, such as pneumonias.

Anaesthetic Complications Problems with anaesthesia, drugs, etc.: These should be rare and the risks will be explained to you by your anaesthetist.

Will the new look last?

Belt lipectomy produces excellent results for patients following massive weight loss. In most cases the results are long lasting, especially if after the operation you avoid weight gain, follow a balanced diet and exercise regularly. Ageing, weight gain/loss, and pregnancies will affect your body and your lower trunk. Remember that realistic expectations are important.

Checklist before coming into hospital

  • Make sure I know all the medications you are taking before surgery.
  • Do not take any Aspirin or blood thinning drugs (which include some homeopathic supplements) for at least 2 weeks prior to surgery. Paracetamol is safe.
  • Oral contraceptives can increase the risk of Deep Vein Thrombosis or Pulmonary Embolism. The contraceptive "pill" should ideally be stopped a month prior to surgery but please use some alternative form of contraception.
  • It is advisable not to smoke six weeks prior to surgery and until complete healing has taken place. Nicotine reduces oxygen levels required for wound healing.
  • Please have a shower in the morning of surgery and do not apply deodorant or any other products (e.g. body lotion, perfume etc.)
  • Please do not have anything to eat (including chewing gum) 6 hours prior to surgery. You are able to drink still clear water up to 2 hours prior to your admission.
  • Please bring your elasticated pressure garment (snug fitting but not too tight) with you to hospital. You have to wear this support for 6-8 weeks after surgery.

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© Copyright Ms Marion Grob, MRCS (Eng), MRCS (Ed), MD (Plast), EBOPRAS, FÄ (Plast) Ger.

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