Summer 2012
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Obesity and the Brain
Going Under: Anesthesia in the Individual with Obesity
Fighting Obesity One Calorie at a Time: An Interview with NFL Veteran Jamie D. Dukes
Volumetry: A New Dimension in Contouring the Massive Weight Loss Individual
16
12
18
20
A peer-reviewed e-journal providing lifestyle and health information for weight loss surgery patients and candidates
Summer 2012
Volume 1, Issue 2
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BEGINNING YOURBARIATRICJOURNEY:Dynamics of a
Healthy Partnership
with Your Surgeon
and Staffp6
Editorʼs Message
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Copyright © 2012 MMC 3BMI Body • Mind • Inspiration—Summer 2012
Dear Readers:
I welcome you to thesecond edition of Body,Mind, Inspiration, andshare with you some greatnews. Finally after 13years of research, theUnited States Food andDrug Administration(FDA) has approved aweight loss drug.Lorcaserin was approvedfor individuals with a BMIof 30kg/m2 or more or27kg/m2 or more with an
overweight-related comorbidity. It works by blocking theappetite signals in the brain creating early satiety.Treatment should be stopped if patients do not lose fivepercent excess body weight (%EBW) at 12 weeks ofdaily use. It will be commercialized by ArenaPharmaceuticals (San Diego, California) and Eisai Inc.(Woodcliff Lake, New Jersey) under the brand nameBelviq.
This month, we present “Beginning Your BariatricJourney: Dynamics of a Healthy Partnership with YourSurgeon and Staff,” by Dr. Barbara McGraw, a bariatricpatient who has undergone Roux-en-Y gastric bypass,four plastic surgeries, and a revisional surgery. In thiscommentary, McGraw outlines the preoperative processof the weight loss surgery (WLS) journey and providesadvice on how to establish good communication withyour surgeon and the bariatric staff. She addresses theimportance of approaching the WLS journey with apositive attitude and patience, communicating yourneeds and concerns effectively during appointments,getting to know your surgeon and staff, and utilizing allavailable resources. This commentary is helpful foranyone considering WLS, as well as for those who arealready on the journey.
Next, we present an article by Kimberly E. Steele andcolleagues elucidating the role of the hypothalamus,dopamine, and dopaminergic receptors in thedevelopment of obesity. I found this article fascinating. I
feel it is important to remember that phenotype plays amajor role as well. Our ancestors did not have arefrigerator in their caves to store food and eat three orfour times a day and they did not have food available ona daily basis either. Our stomachs are far too big for thequantity and quality of food available to us in the 21stcentury, and sedentary lifestyles make it even worse.Think about how little the Chilean miners had to eat on adaily basis and yet they all survived for so longunderground. My patients sometimes say to me, “I neverthought we needed so little to function.”
Also in this issue, Drs. Vipul Shah and Stephanie B.Jones give an overview of the challenges individuals withobesity might face when undergoing anesthesia. Theyoutline techniques and products that anesthesiologistscan use to make going under more safe for the individualwith obesity.
Dr. Terrence Fullum presents an interview with JamieD. Dukes, an NFL veteran who underwent WLS. Dukestalks about the Put Up Your Dukes Foundation, aprogram dedicated to fighting obesity. For example,Duke’s foundation has been instrumental in bringinghealthier food services to former NFL players andstrenghening physical education programs in schoolsthroughout the Untied States.
Finally, Dr. Michele Shermak writes on reconstructivesurgery after massive weight loss and explains howimportant it is to not only trim the redundant skin, butalso to add some volume to patients when performingbody contouring procedures.
Wherever you may be in your quest to get fit andhealthy, we hope BMI offers you helpful information,encouragement, and support. BMI
Sincerely,
Raul J. Rosenthal, MD, FACSClinical Editor, BMI
Raul J. Rosenthal, MD, FACS,Clinical Editor, Body, Mind,Inspiration, Program Directorof Minimally Invasive Surgery,Director of the MinimallyInvasive Fellowship Program,Director of the Bariatric andMetabolic Institute, andDirector of the GeneralSurgery Residency Program,Cleveland Clinic Florida—Weston, Fort Lauderdale,Florida.
Summer 2012
Volume 1, Issue 2
Editorial Advisory Board
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Copyright © 2012 MMC4 BMI Body • Mind • Inspiration—Summer 2012
CLINICAL EDITOR
Raul J. Rosenthal, MD, FACSProgram Director of Minimally InvasiveSurgery, Director of the Minimally InvasiveFellowship Program, Director of theBariatric Institute, and Director of GeneralSurgery Residency Program, ClevelandClinic Florida—Weston, Fort Lauderdale,Florida
EDITORIAL ADVISORY BOARD
Susan Gallagher Camden, RN PhD WOCN,CBN, HCRM CSPHPSenior Clinical Advisor, CelebrationInstitute, Inc., Houston, Texas
Tracy Martinez, RN, BSN, CBNProgram Director, Wittgrove BariatricCenter, La Jolla, California
Melodie K. Moorehead, PhD, ABPPBoard Certified in Clinical HealthPsychology, JFK Medical Center, BariatricWellness and Surgical Institute, Atlantis,Florida
Harry Pino, PhDDirector of Clinical Exercise PhysiologyProgram, RecoverHealth Center, New York,New York; Medical Center, Stony Brook, NewYork
Craig B. Primack, MD, FAAPMedical Bariatrician/Certified MedicalObesity Specialist/Co-Medical Director,Scottsdale Weight Loss Center PLLC,Scottsdale, Arizona
Wendy Scinta, MD, MS, FAAFP, FASBPMedical Director, Medical Weight Loss of NY,BOUNCE Program for Childhood Obesity,Manilus, New York; Clinical AssistantProfessor of Family Medicine, UpstateMedical University, Syracuse, New York
Kimberley E. Steele, MD, FACS,Assistant Professor of Surgery, The JohnsHopkins Center For BariatricSurgery,Baltimore, Maryland
Christopher D. Still, DO, FACN, FACPDirector, Center for Nutrition and WeightManagement, Geisinger Health System,Danville, Pennsylvania
Copyright © 2012 MMC 5BMI Body • Mind • Inspiration—Summer 2012
Summer 2012 Volume 1, Issue 2
Table of Contents
Going Under:
Anesthesia in the Individual with Obesity 16
Fighting Obesity One Calorie at a Time
An Interview with NFL Veteran
Jamie D. Dukes 18
Volumetry: A New Dimension in Contouring
the Massive Weight Loss Individual 20
Obesity and the Brain 12
BMI BODY MIND INSPIRATION EDITORIAL STAFF
Editor
Raul J. Rosenthal, MD, FACS
Program Director of Minimally Invasive Surgery,
Director of the Minimally Invasive Fellowship
Program, Director of the Bariatric and Metabolic
Institute, and Director of the General Surgery
Residency Program, Cleveland Clinic Florida—
Weston, Fort Lauderdale, Florida.
Vice President, Executive Editor
Elizabeth A. Klumpp
Matrix Medical Communications
West Chester, Pennsylvania
Associate Editor
Angela M. Hayes
Matrix Medical Communications
West Chester, Pennsylvania
Associate Editor
Kimberly B. Chesky
Matrix Medical Communications
West Chester, Pennsylvania
BMI BODY MIND INSPIRATION BUSINESS STAFF
President/Group Publisher
Robert L. Dougherty
Matrix Medical Communications
West Chester, Pennsylvania
Partner
Patrick D. Scullin
Matrix Medical Communications
West Chester, Pennsylvania
Vice President, Business Development
Joseph J. Morris
Matrix Medical Communications
West Chester, Pennsylvania
EDITORIAL CORRESPONDENCE should be directed to
Executive Editor, Matrix Medical Communications,
1595 Paoli Pike, Suite 103, West Chester, PA 19380.
Toll-free: (866) 325-9907; Phone: (484) 266-0702;
Fax: (484) 266-0726;
E-mail: eklumpp@matrixmedcom.com
ADVERTISING QUERIES should be addressed to Robert
Dougherty, President/Group Publisher, Matrix
Medical Communications,1595 Paoli Pike, Suite 103,
West Chester, PA 19380. Toll-free: (866) 325-9907;
Phone: (484) 266-0702; Fax: (484) 266-0726;
E-mail: rdougherty@matrixmedcom.com
1595 Paoli Pike
Suite 103
West Chester, PA 19380
BMI Body Mind Inspiration [ISSN TBD] is published
digitally four times yearly by Matrix Medical
Communications.Copyright © 2012 Matrix Medical
Communications. All rights reserved. Opinions
expressed by authors, contributors, and advertisers
are their own and not necessarily those of Matrix
Medical Communications, the editorial staff, or any
member of the editorial advisory board. Matrix
Medical Communications is not responsible for
accuracy of dosages given in the articles printed
herein. The appearance of advertisements in this
journal is not a warranty, endorsement, or approval
of the products or services advertised or of their
effectiveness, quality, or safety. Matrix Medical
Communications disclaims responsibility for any
injury to persons or property resulting from any
ideas or products referred to in the articles or
advertisements. This publication provides basic
information about a broad range or medical
conditions. It is not intended to serve as a tool for
diagnosing illness, in prescribing treatments, or as a
substitute for the physician/patient relationship. All
persons concerned about medical symptoms or the
possiblity of disease are encouraged to seek
professional care from an approprpiate healthcare
provider.
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Copyright © 2012 MMC6 BMI Body • Mind • Inspiration—Summer 2012
The decision to have bariatric surgery involves a life-
long relationship with your surgeon and his or her
staff. Building a successful relationship is crucial to
acquiring the lifestyle changes that will keep your weight
loss and new healthier lifestyle. The requirements of
completing your journey to a healthy life may be rigorous
and difficult to achieve. In my experience, many patients
seem to fix blame for their obesity on other people and
circumstances from their past and present. Some seem to
expect that the staff and support system will fix them,
when in reality the weight loss journey requires much
work on the patient’s part. Developing a healthy, mature
attitude while approaching the weight loss surgery (WLS)
journey with personal responsibility, an adventurous
heart, and team spirit will benefit you immensely when
connecting to your medical caregivers.
BUILDING A PARTNERSHIP WITH YOUR SURGEONAND STAFF
First and foremost, I recommend that you approach the
WLS journey simply as a person, rather than a medical
disease defined as morbid obesity. Remember that
members of the bariatric staff and even your surgeon are
human and face their own daily stresses and pressures.
During your initial consultation and throughout your
WLS, you should aim to establish an egalitarian
relationship among yourself, your surgeon, and his or her
staff. The doctor and staff will have crucial demands you
will have to follow, and in turn, they should be respectful
of your fears and do their best to help you address them.
It is also important that you expect to receive as well as to
BEGINNING
YOUR BARIATRIC
JOURNEY:
Dynamics of a Healthy
Partnership with Your
Surgeon and Staff
by Barbara McGraw, PhD
This article will discuss the dynamics of a relationship between a bariatric patient, surgeon, and office staff. It also lists
areas of expectation required for complete adherence during the initial consultation and through a patient’s weight loss
surgery journey.
Dr. Barbara McGraw was born and raised in
Northern California and was educated as a
California public school teacher and counselor
in Music and Special Education. She continued
her masters and doctorate in counseling and
consulting, focusing on educational
institutions and nonprofits. Emphasis was centered on
relationships and team building.
Very athletic and active, Barb did not become obese until she
developed genetic type 2 diabetes mellitus during her forties. As
she became more immobile, her two adult children were
saddened that her new granddaughter would not have the quality
of life with her as they had. In 2004, she researched bariatric
surgery and was immediately approved by her insurance to
undergo an adjustable gastric banding procedure.
She was followed up and received four plastic surgeries. After
losing 90 percent of her excess weight by walking several half
marathons and 10Ks, she suffered an unexpected heart attack in
2010. A revision from band to gastric bypass was performed and
she experienced improvement of her type 2 diabetes mellitus.
Her passion is now facilitating good, healing relationships
between patients and surgeons. She also uses her own
experiences to facilitate relationships between plastic surgeons
and other caregivers in the field of bariatrics, both from a doctor’s
and patient’s perspective.
MY BARIATRIC JOURNEY
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Copyright © 2012 MMC 7BMI Body • Mind • Inspiration—Summer 2012
give respect and common courtesy from and to everyone
along your medical journey.
Many patients with morbid obesity have experienced
discrimination most of their lives and do not feel
accepted for who they are. It is important to remember
that on this journey you are part of a team whose
members (medical personnel and peers) will likely accept
you as you are and will work with you during the changes.
Challenges come with any of life’s journey involving
drastic lifestyle changes. Remember this is a journey, not
a destination. Discipline will define and accomplish your
goals, and a positive attitude and mindset will be crucial
to your WLS journey success.
At certain times, you may feel discouraged, in pain, or
impatient. It is helpful to realize that on any given day
circumstances may not fall in place as expected. Be
patient and kind. This will always help you achieve your
goals.
An example of this can be seen in my own WLS
experience. During one appointment, I came in to the
office ready for my initial WLS to take place in two
weeks. I had completed all of the required tests and
preoperative appointments. My surgeon looked at my
endoscopy report and found that the nurse had missed a
short sentence indicating that there was a small amount
of “unidentified fluid” in my stomach. The surgery was
postponed until a biopsy was done. It took two more
months to receive the results, and surgery was then
rescheduled. I was furious inside, but I calmly said it was
okay. Everybody on the team was doing his or her best
and I understood that. I smiled and began to walk out the
door with a whole new set of papers to complete. As I
paused to look at a poster, I overheard the surgeon say
that I was a “nice lady and will be good to work with.” I
was so glad that I developed that first impression during a
conflict. This became the basis of an eight-year
relationship that still continues and that has endured
many medical hardships. I believe that the strong trust
and respect between my surgeon and the staff helped
carry and me through every rough patch. It helped that I
could be flexible and patient when situations did not turn
out as well as I expected.
WORKING ON COMMUNICATION
It is crucial during all appointments that you express
your concerns clearly. You might consider writing down
your questions and concerns to ensure you stay focused.
It might also help to bring an advocate (family member or
friend who knows you well) with you to the
appointments. This person can fill in the gaps if the
consultation liaison misses what you are trying to
communicate.
Many medical professionals depend on technology to
keep your medical information timely and accurate. This
may involve your doctor having an electronic device in
the exam room with you. I remember the first time I
experienced a “laptop surgeon.” Everything I was
communicating to him was intense and from my heart. All
I saw was the top of his head behind the screen of his
device. I stopped talking, smiled, and made a funny
comment on his hair. He got the point. I stopped reading
my notes and he stopped typing. We made eye contact
and I felt like he heard and acknowledged me as he asked
probing questions. Then, during a brief pause he went
back and recorded a summary of what was discussed.
The important concept is to keep every clinical
appointment focused on information, but express what
you feel your surgeon or the bariatric staff member needs
to hear. Like any new relationship, this will take time to
develop, but this will be the foundation of success for all
that comes ahead.
YOUR INITIAL CONSULTATION
Discussing your procedure. By the time you have
your initial consultation, the different types of bariatric
procedures for which you qualify will be the main topic of
discussion. If the surgeon has an orientation information
seminar, each procedure will be graphically explained,
sometimes with accompanying handouts, with the pros
and cons of each procedure. Hopefully you have also been
researching each procedure on your own. Now is the time
to discuss with your surgeon which procedure you both
think will be best.
Discussing your health history. At this point, you
should have filled out a comprehensive form explaining
your past health history, medications, family history,
lifestyle and eating habits, past experiences with weight
loss efforts, and whatever else your surgeon and staff
need to know to apply for insurance coverage (if
applicable) and keep you safe during your journey.
It is critical that you are brutally honest with all your
health issues involving other specialists and medications.
Challenges come with any of life’s journey involving drastic life style changes. Remember
this is a journey, not a destination. Discipline will define and accomplish your goals, and a
positive attitude and mindset will be crucial to your WLS journey success.
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You must advocate for yourself to make sure these
specialists stay in contact during your WLS journey.
Neurologists, cardiologists, endocrinologists, and any
other specialist who treats you regularly, especially
involving medication, must know what you are planning
step by step. If you are part of a health maintenance
organization (HMO), you likely have a primary care
physician (PCP) who will pull together all of these
authorizations.
Consultations between your PCP and your bariatric
surgeon may be necessary. Some WLS procedures,
especially those involving malabsorption, will not be
possible if you have medical conditions that require you
to take medications. Complications from medical
conditions, such as sleep apnea, heart conditions, and
diabetes, just to mention a few, can be fatal to you during
and immediately after surgery if not adequately planned
for.
Of crucial importance is reporting lifestyle habits that
could hinder the surgical process and the rest of your
WLS journey. Smoking and recreational drug and alcohol
use fall into this category. If you engage in any of these
habits, your surgeon will likely have guidelines for you to
follow on limiting or probably totally ceasing these
activities. Part of the preoperative process will be
outlining a strategy of dealing with any habit that may
sabotage your weight loss goals. Do not be afraid to tell
the truth and ask for help in finally combatting these
lifestyle habits.
Your bariatric surgeon and/or insurance company have
required tests and evaluations of you to qualify for
surgery. Each medical clinic and test will have to report
what happened during your appointment. It will be your
responsibility to make sure these reports get to your
bariatric surgeon’s office. Many times I gave up on faxing
reports or sending x-rays between offices because there
were gaps with such reports being sent or received. Since
these are required for surgery clearance and would delay
the date, I made a special effort to hand deliver my
paperwork to the appropriate bariatric office person as
soon as they were available. These days, electronic
transfers are common. Lab test and images may be
recorded on compact disks. You may also want to get a
hard copy of everything for your personal records.
PSYCHOLOGICAL EVALUATION
The psychological evaluation can help to access your
mental and emotional health. Remembering what and how
to eat, adjusting to constantly taking new medications
while revising your old ones, and planning your daily meal
intake are just a few of the changes you will have to make
that will require you to be mentally healthy. These may
seem simple, but as your body physically changes, it is
important that you maintain your psychological well-
being.
Secondly, it is imperative that an individual be
emotionally stable enough to handle the rigorous changes
WLS will bring to your life. Patients may have developed
obesity through a lifestyle of addiction, various abuse
issues, failed relationships, depression, or other issues.
None of these issues in themselves will disqualify a
patient from WLS, but evaluation needs to be made on
how stable he or she is to stand up to the challenges of a
major surgery and possible complications during these
drastic life changes. Such patients can benefit from a
strong support system to help them improve upon these
emotional challenges. If a patient’s emotional stability
challenges are assessed as too great, he or she may be
told to continue counseling for awhile longer until he or
she can learn to accept and deal with the severe changes
WLS will make on his or her life.
Some patients may believe losing weight is a silver
bullet to solve all these emotional issues. Often times, it
may be easy to place blame when your personal
expectations are not met. This is where self advocacy and
responsibility for your own feelings and behavior become
paramount in developing emotional maturity and stability.
Emotional issues can improve with weight loss, but
only as an individual grows stronger, address these issues,
and realizes that a lot of other serious hurdles may lie
ahead. Dealing with addictions that cause emotional
eating and understanding changes in body image are just
two of the possible major challenges ahead. Working with
a qualified counselor and a bariatric support system is
essential in WLS success. Being emotionally stable is
paramount in achieving a new healthy lifestyle. Emotional
instability can sabotage a patient’s success if it is not
dealt with in a positive manner.
Copyright © 2012 MMC8 BMI Body • Mind • Inspiration—Summer 2012
Some patients may believe losing weight is
a silver bullet to solve all these emotional
issues. Often times, it may be easy to place
blame when your personal expectations are
not met. This is where self advocacy and
responsibility for your own feelings and
behavior become paramount in developing
emotional maturity and stability.
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Copyright © 2012 MMC 9BMI Body • Mind • Inspiration—Summer 2012
PREOPERATIVE PERIOD
After the initial consultation you will have many
medical appointments and tests to complete that will be
used to determine your qualifications for the bariatric
procedure on which you have decided. In addition, it is
common for most insurance companies and your surgeon
to require a supervised fitness and weight loss
requirement before surgery. This may require weeks or
even months of adhering to a diet and exercise plan. In
my program, the requirement was be lose 10 percent of
your starting weight. You will be on a supervised diet,
usually protein shakes with limited solid food, nutritional
counseling, supplemental vitamins, which you might be
required to take for life, and a modified exercise regimen.
Patients may feel offended by this requirement and see
it as just another weight loss program that they have
failed many times before. However, this can be a
wonderful opportunity to test your resolve and
understand before you have your surgery what will be
required post surgery and for years to come. Losing
weight preoperatively (even a little) may make your
procedure and recovery period easier. The simple
exercises will help you get in shape to be more mobile
and prevent postsurgical complications. Believe me, you
will be grateful for completing your preoperative special
nutrition and fitness plan when you first try to get out of
your hospital bed and walk. You will also learn to
appreciate this phase of your journey in the future.
GET TO KNOW THE OFFICE STAFF
There will be many questions and issues that come up
during your life-long WLS journey. An established clinical
bariatric practice will have staff members fulfilling certain
roles. It is important that you become familiar with these
people and know how to contact them, whether they are
able to provide you with a phone number or e-mail
address. Early on, you should also ask if there is a phone
number to call in case of emergency. This is a standard of
care that patients should expect.
The following section lists different bariatric staff
members you may encounter along with their roles.
Administrative assistant. Get to know the surgeon’s
administrative assistant, who may also fill the roles of
office manager or personnel director. This person usually
handles the surgeon’s schedule. You can contact this
person with questions about your appointment and the
doctor’s time agenda (e.g., time out of office). The
administrative assistant can direct your questions and
concerns to other departments as needed (e.g., hospital
policy).
Insurance coordinator. This person handles
insurance authorizations and will know exactly what your
policy will and will not cover. The insurance coordinator
should be able to advise on any pre-requisite
requirements for surgery, such as nutritional and
excersise classes.
You will probably be anxious to keep in touch and see
how your insurance coverage is handled. Your surgeon
will write a comprehensive insurance request with
medical terms explaining how you qualify for the
procedure you have chosen. You may be able to start your
preoperative appointments with other medical specialists
during the approval process if your insurance authorizes
you to do so. It is important that you do not jump ahead
of your medical plan because you may be liable for
medical bills if not granted insurance approval.
Ask the insurance coordinator if there is an estimated
time line you can follow. Believe that the insurance
coordinator is working as fast as the system will allow.
Insurance is very complex.
For those who have limited insurance, large copays, or
are in between insurance coverage or have no insurance
at all, some offices have finance plans available for which
you may qualify. Ask your practice if they offer such
assistance and, if so, ask to meet with someone to discuss
your financing and payment options. There is also, of
course, the option to pay out of your own pocket. You will
find out that when you calculate the past expenses
caused by obesity, the investment you make for your
surgery will be paid back many times over as obesity
issues are resolved over time. Just the medications and
food savings are substantial.
Nursing staff. The nursing staff will be your main
contacts for any medical issues or questions you have.
You may be given a manuel for reference on your specific
surgery that might include certain complications and
their symptoms. The nursing staff will likely be
responsible for arranging your preoperative classes.
During these preoperative classes, you learn important
details about your surgery, including the following:
1. How to prepare for surgery
2. What the hospital will and will not provide
3. Your diet immediately before and after your surgery
4. Addressing any concerns with your anesthesiologit
prior to your surgery
5. How to exercise after surgery
6. How to prepare for recovery
7. Your surgeon’s specific requirements before, during,
and after surgery.
It is usually the nursing staff’s primary responsibility to
relay information on your medical issues directly to your
surgeon. Any issue you have should be directed to the
appropriate person.
Support group leader and members. Immediately
after your interest in WLS and when you are fairly certain
of your surgeon, start attending support groups if your
program offers them. Preoperative patients are always
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welcomed, and you will get a firsthand idea of what to
expect on your WLS journey. Many bariatric centers of
excellence (now accredited jointly by the American
Society for Metabolic and Bariatric Surgery [ASMBS] and
American College of Surgeons [ACS] under the new
Metabolic and Bariatric Surgery Accredititation and
Quality Improvement Program [MBSIQP]) have a mentor
program where the long-term patients of your chosen
procedure will walk with you on your journey. They can
help answer the majority of your questions as they know
your surgeon’s procedures and preferences. If this mentor
does not know the answers, he or she can help point you
to the right source.
The support group leader(s) can be a valuable
resource for you through the whole hospital experience,
from the preoperative period and complications to future
plastic surgery, providing resources along the way. A
support group leader will provide both pre and post
operative advice on any subject. Medical, physical,
nutritional, psychological, and social concerns related to
WLS will be addressed. If you are curious about resources
available to you, it is import that you just ask. Some
examples of resources and programs include exercise
classes; social events like the Walk For Obesity, parties,
and clothing exchanges; counseling on self image issues,
emotional eating, and nutrition. Even surgeons come to
events periodically. With so many people and resources,
rest assured that you are part of a caring family.
Just one month after my surgery, I connected with
WLS people in my area, the Central Coast Redwoods of
California, via social networking websites. The patients
covered about nine different surgeons and all the
procedures. Not a weekend went by where we weren’t
offered an activity to do that we all shared in planning
and implementing. We walked the Redwoods and the
beaches; trained for short races; had monthly social get-
togethers (sometimes with clothing and recipe
exchanges); and went scuba diving, horseback riding, and
took belly-dancing lessons together. We were exploring
together all the activities we were never able to do
because of our obesity. In my case, it had been 20 years
since I was able to attempt such activities. We had fun
and helped to keep each other accountable for the WLS
journey with support.
CONCLUSION
As your WLS journey begins, it is imperative you
establish solid relationships based on trust and respect
with your surgeon, the bariatric staff, and support system.
Without this, you may become fragmented and confused
learning all the procedures and behavioral changes for a
healthier lifestyle. It is also imperative to begin your
journey with maturity and a positive attitude. Try your
best to adhere to all of the plans and processes, and be
sure to educate yourself as much as possible. Most
important of all, however, is to realize that you are a
person, not a disease, and this is your journey, meaning
you will likely will get out what you put into it. I have (for
the most part) enjoyed my WLS journey and the
wonderful results of having more energy, better
relationships, and an opportunity to better fulfill my life
goals. I believe I would have never succeeded without a
strong support system in place to help me understand
each step of the way. Now, I am engaging in the process
that is most exciting of all—paying it forward.
During my WLS journey as a high-risk patient, I
found that displaying a sense of humor once in a
while helped myself, the staff members, and my
surgeons through serious and scary times. This
cartoon demonstrates my personal sense of humor
about the WLS journey.
Illustration by James W. ElstonJames Elston Studio
http://www.jameselston.com
Copyright © 2012 MMC10 BMI Body • Mind • Inspiration—Summer 2012
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Copyright © 2012 MMC 11BMI Body • Mind • Inspiration—Summer 2012
RESOURCES
1. Cook, Coleen. Success Habits of Weight Loss Surgery
Patients. Salt Lake City, Utah: Bariatric Support Centers
International; 2012.
Available at: http://bsciresourcecenter.com/proddetail.php?
prod=3.SHBook
A primary resource for patients on the dynamics and life
long issues of WLS. An educational resource for support for
patients covering comprehensive subjects throughout the
WLS journey. Many international seminars and training
opportunities for support groups.
2. Groopman, Jeromne. How Doctors Think. 1st Edition. New
York, New York: Houghton Mifflin Company; 2007.
Groopman, Jeromne. The Anatomy of Hope: How People
Prevail in the Face of Illness. New York, New York:
Random House Trade Paperbacks; 2005.
Dr. Groopman writes clear and concise books for patients
who want to learn how the majority of doctors will interact
with them. Patients who want to learn how to communicate
their needs and expectations effectively to medical medical
professionals should read How Doctors Think. The
Anatomy of Hope: How People Prevail in the Face of
Illness is excellent for teaching both doctors and patients
how to keep hope and support alive during difficult health
issues
3. Obesity Help. http://www.obesityhelp.com/
A network for bariatric doctors and patients, ObesityHelp is
a comprehensive interactive website with forums on any
WLS you can imagine. Each doctor has his or her own
forum.
4. Bariatric University. http://www.bariatricu.com
Founded in 2005 by Susan Lassetter and Dana Schroeder
from the Silicon Valley Bay Area of California, Bariatric
University was created at the beginning of my WLS journey.
Bariatric University is an excellent educational resource for
understanding the life coaching model in comparison to the
direct lecturing method in achieving long-term goals in you
WLS journey. Bariatric University was the main place for my
initial training and support.
5. Dr. Sharma’s Obesity Notes http://www.drsharma.ca
Dr. Arya Sharma is the Chair of Obesity Research and
Management at the University of Alberta, Canada. He sends
out a daily e-mail blog, which is open to anybody, on various
issues related to obesity both from the physicians’ and
patients’ perspective.
6. Publications by Abraham Vergheses.
http://www.abrahamverghese.com/
Dr. Vergheses’ deep interest in bedside medicine and his
reputation as a clinician, teacher, and writer led to his being
recruited to Stanford University in 2007 as a tenured
professor. His books and resources explain how imperative it
is for patients and doctors to have close relationships for the
purpose of healing. He spent many years being close to
human immunodeficiency virus (HIV) patients and their
families and writes about his experiences in relationships
made during that time. BMI
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Copyright © 2012 MMC12 BMI Body • Mind • Inspiration—Summer 2012
Each year, the number of patients with morbid
obesity in the United States increases alarmingly.
When traditional weight loss methods fail, the only
successful alternative is bariatric surgery. However,
despite the indisputable effectiveness of bariatric
surgery, there remain those who have less successful
weight loss than others. This cannot be attributed
entirely to the type of procedure itself but may in fact be
more complicated and involve genetics and
neurochemical factors. In this article, we review the work
that has been done on the neurotransmitter dopamine
and how it may relate to the population with obesity.
INTRODUCTIONThe number of individuals with morbid obesity in the
United States is increasing at an alarming rate. When
traditional weight loss methods fail, the best alternative
is usually bariatric surgery. But why do some bariatric
patients have more successful weight loss than others?
Despite the indisputable effectiveness of bariatric
surgery in the aggregate, there remains significant inter-
individual variability in the treatment response.1 This
difference cannot be attributed entirely to the type of
procedure (i.e. restrictive vs. malabsorptive) that the
patient undergoes. Something much more complicated,
involving both genetics and environment and mediated
through neurochemical factors, is at play.
It is well known that caloric intake is regulated by the
brain, notably the hypothalamus. Our subconscious mind,
as it were, informs us of when and how much to eat. For
millennia, these brain mechanisms have prevented
starvation and ensured the continuance of our species.
Unfortunately, what was adaptive in the relatively
calorie-restricted environment of the past has become a
liability in our current obesogenic environment, with its
abundance of inexpensive, highly caloric, and generously
portioned foods. In this environment, it is difficult at
times for almost all of us to resist the urge to overeat.
But for the individual with a genetic predisposition to
obesity, this abundance of food can fuel an addiction that
is potentially as harmful as cigarettes, alcohol, or
cocaine.
OBESITY AND
THE BRAIN
by Kimberley E. Steele, MD, FACS; Thomas H.
Magnuson, MD, FACS; Anne O. Lidor MD, MPH,
FACS; Dean F. Wong, MD; and Michael A.
Schweitzer, MD, FACS
Drs. Steele, Magnuson, Lidor, and Schweitzer are all from the Department of Surgery, The Johns Hopkins
University School of Medicine, Baltimore, Maryland. Dr. Wong is from the Department of Neuroradiology, The
Johns Hopkins University School of Medicine.
If an individual carries a genetically reduced
sensitivity to dopamine, he or she may require
excessive reward stimulation—in effect, a “fix”—
just to feel normal. For certain individuals, this may
take the form of overeating, resulting in obesity,
while others may manifest a tendency toward
compulsive gambling, shopping, or other behaviors.
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Copyright © 2012 MMC 13BMI Body • Mind • Inspiration—Summer 2012
NEUROCHEMICAL MECHANISMS IN THE BARIATRIC
PATIENT
Research in neuroscience has revealed that a common
mediator of many addictive behaviors is the
neurotransmitter dopamine, which some have termed the
pleasure molecule. Dopamine is the primary regulator of
eating behavior2 and is released in response to both
appropriate and excessive eating.3 Abnormal regulation
of this molecule may explain why individuals with obesity
tend to eat more carbohydrate and energy-dense foods
than their nonobese counterparts. If an individual carries
a genetically reduced sensitivity to dopamine, he or she
may require excessive reward stimulation—in effect, a
“fix”—just to feel normal. For certain individuals, this
may take the form of overeating, resulting in obesity,
while others may manifest a tendency toward compulsive
gambling, shopping, or other behaviors. The relevance
for the bariatric surgeon is that understanding of these
neurochemical mechanisms may shed light on why some
patients fail weight loss surgery. A diagnostic test, if it
can be found, that would predict which patients were
predisposed to fail would be an important tool for the
bariatric surgeon, enabling customized pre-operative
planning and postoperative care.
Recent efforts at understanding the brain mechanisms
of reward behavior have made use of positron-emission
computed tomography (PET). PET is a nuclear medicine
imaging technique that can display dynamic
neurochemical changes in the brain. As such, it is
considered a “functional” imaging modality, offering
information beyond what can be gathered by strictly
anatomic imaging, such as a computed tomography (CT)
scan. In the clinical setting, PET imaging is well known
for its role in differentiating actively metabolizing
metastatic disease from other tissues. But in research
centers, PET imaging has also been instrumental in the
elucidation of central dopaminergic pathways and their
relation to reward-based behaviors.4
OBESITY AND DOPAMINE
In 2001, Dr. Gene-Jack Wang used PET imaging to
demonstrate that patients with obesity had reduced
dopamine receptor availability when compared to
controls, and that there was an inverse linear
relationship between dopamine receptor availability and
body mass index (BMI); that is, the higher the BMI, the
lower the dopaminergic activity.5 Two hypotheses have
been proposed to explain this relationship. The first is
that individuals with obesity are born with a primary
deficiency in dopamine receptors, with an associated
under stimulation of dopaminergic reward circuits. This
is thought to result in overeating as a compensatory
mechanism. The second explanation is that dopaminergic
receptor activity is initially normal, but becomes down-
regulated as a result of chronic over stimulation of
dopaminergic pathways in individuals with obesity, in a
manner analogous to the insulin insensitivity seen in
such patients.
Bariatric surgical patients present us with a uniquely
valuable resource to determine which of these
hypotheses is correct. If obesity is characterized by a
primary dopamine receptor deficiency, one would expect
that this deficiency would not improve substantially
following gastric bypass surgery. On the other hand, if
decreased receptor density is due to receptor down
regulation, the marked weight loss produced by gastric
bypass surgery could be expected to result in increased
receptor availability, as food intake is decreased and the
attendant chronic dopaminergic overstimulation is
alleviated.
RESEARCH TO PRACTICE
Our group studied five female subjects ranging in age
from 20 to 38 years old, all of whom underwent
laparoscopic Roux-en Y gastric bypass (RYGB).6 The
mean BMI was 45kg/m2. These subjects underwent pre-
operative brain magnetic resonance imaging (MRI), as
well as PET imaging with the injection of [11C]
raclopride, a radioligand for D2/D3 receptors. Five
regions of interest were studied, including the ventral
striatum, anterior putamen, posterior putamen, anterior
caudate nucleus, and posterior caudate nucleus. Six
weeks after undergoing standard RYGB, each subject was
weighed. The average weight loss six weeks following
surgery was 25.4lbs. The five patients then underwent
postoperative PET imaging with [11C] raclopride. We
found that dopamine D2 receptor availability, measured
as [11C] raclopride binding, increased in female patients
who lost weight following RYGB. These findings were
consistent with Wang et al5 in showing an inverse
relationship between BMI and dopamine receptor
availability. Since previous work had been limited to
comparisons of obese subjects with matched controls,
the question of whether decreased dopamine D2
receptor availability was a cause or effect of increased
BMI remained unclear. Our data, though limited to only
five subjects, did suggest that dopamine receptor binding
potential increases in response to weight loss, implying
that decreased receptor density is a consequence and
not a cause of obesity, and thus, arguing against the
concept that obesity is caused by a primary deficiency of
dopamine receptors.
One year following our study, Dunn et al7 published
the only other study reporting dopamine receptor
availability after RYGB. Five female subjects, age 41 to
52 years old with a mean BMI of 43kg/m2, were enrolled
in the study. Four subjects underwent RYGB and one
subject underwent laparoscopic sleeve gastrectomy
(LSG). A very similar PET protocol was utilized, except
that the radioligand [18 f] fallypride was used instead of
[11C] raclopride. To our surprise, they obtained the
opposite of our results: dopamine D2 receptor availability
decreased following bariatric surgery. While both
protocols were very similar, there were some differences
that may have accounted for discrepant findings. The
most likely contributing factor was a difference in age.
The mean age in Dunn’s study was 14 years greater than
ours. Age is known to affect the dopaminergic response.
As middle age approaches, estrogen and progesterone
levels decrease, and this is associated with less D2
receptor expression and function.8
Furthermore, both our study and Dunn’s study were
limited by small sample size, so larger studies are
needed.
CONCLUSION
Indeed, it may turn out that both of the hypotheses
regarding dopamine could be correct. Some individuals
might carry a genetic deficiency in dopamine receptors,
while others might develop down regulation of receptors
due to overstimulation. A further understanding of these
neurochemical mechanisms may have important
implications for both surgical and nonsurgical
management of obesity, including the selection of
patients for different surgical procedures and the
prediction of long-term outcomes following bariatric
surgery. Ultimately, we hope that PET imaging of the
brain will one day serve as a useful guide in the
management of the bariatric surgical patient.
REFERENCES
1. Melton-Meaux GB, Steele KE, Schweitzer MA, et al.
Suboptimal weight loss after gastric bypass surgery:
correlation of demographics, co-morbidities, and
insurance status with outcomes. J Gastrointest Surg.
2008;12(2):250–255.
2. Chau DT, Roth RM, Green AI. The neural circuitry of
reward and its relevance to psychiatric disorders. Curr
Psychiatry Rep. 2004;6:391–99.
3. Comings DE, Blum K. Reward deficiency syndrome:
genetic aspects of behavioral disorders. Prog Brain Res.
2000;126:325–341.
4. Volkow ND, Fowler JS, Wang GJ, Telang BF. Imaging
dopamine’s role in drug abuse and addiction.
Neuropharmacology. 2009;56 (Suppl 1):3–8. Epub 2008
Jun 3.
5. Wang GJ, Volkow ND, Logan J, et al. Brain dopamine and
obesity. Lancet. 2001;3:354–357.
6. Steele KE, Prokopowicz GP, Schweitzer MA, et al.
Alterartions of central dopamine receptors before and
after gastric bypass surgery. Obes Surg. 2010;20:369–374.
7. Dunn JP, Cowan RL, Volkow ND, et al. Decreased
dopamine type 2 receptor availability after bariatric
surgery: preliminary findings. Brain Research.
2010;123–130.
8. Bazzett TJ, Becker JB. Sex differences in the rapid and
acute effects of estrogen on striatal D2 dopamine
receptor binding. Brain Res. 1994;637:163–172. BMI
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Copyright © 2012 MMC16 BMI Body • Mind • Inspiration—Summer 2012
Whether this is your first or your fifth operation,
going under anesthesia can be an anxiety
provoking experience. As anesthesiologists,
patients often ask us: “How will you know if I am getting
enough anesthesia?” or “Will I feel pain?” While nothing
in life is completely free of risk, advances in technology
and monitoring have made “going under” much safer
than it was in the past. Your anesthesiologist is trained to
look for signs that you are adequately anesthetized
during surgery, and we have many medications to help
alleviate pain.
PREOPERATIVE CONSIDERATIONSIf you are an individual with obesity, you may have
heard rumors that can make you even more apprehensive
about anesthesia. The good news is that anesthesia is
still safe for people with obesity, although there are
special considerations that are specific to this population.
Along with all the standard preparations, such as
determining which medications to stop and which to
continue to take up to the day of surgery, individuals
with obesity often have other health conditions that can
play an important part in how well they do during and
after the operation.
Individuals with obesity are at a higher risk for
diabetes.1 If you have diabetes, it is important to
continue to be vigilant about blood sugar control as
uncontrolled diabetes can complicate surgery and
recovery. Even if your diabetes is well controlled, your
drug regimen may need to be adjusted prior to going to
the operating room. If you are taking insulin, a general
rule is to take half your normal dose of long-acting
insulin the night before surgery because you will not be
eating after midnight the day of your operation. The
exact details are tailored to each individual and you
should discuss your diabetic management with your
primary care physician (PCP) prior to surgery. Individual
with obesity also have a higher risk of obstructive sleep
apnea (OSA). If you have OSA, it is important to use
your continuous positive airway pressure (CPAP)
machine as prescribed. If you think you may have OSA
but have not been diagnosed, discuss your options with
your PCP.
OPERATIVE CONSIDERATIONSNow comes the big day. The anesthesiologist will tailor
the type of anesthetic to best suit the needs of you and
your surgeon. The anesthesiologist may offer deep
Going Under:
Anesthesia in
the Individual
with Obesity
by Vipul Shah, MD, and Stephanie B. Jones, MD
Dr. Shah was a Resident in the Department of Anesthesia, Critical Care and Pain Management, Beth
Israel Deaconess Medical Center, Clinical Fellow in Anaesthesia, Harvard Medical School, Boston,
Massachusetts at the time this paper was written. Dr. Jones is Vice Chair for Education,
Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center,
Boston, Massachusetts
Many individuals with overweight and obesity undergo anesthesia for both major and minor procedures. While advances in
anesthesia have made "going under" much safer, there are certain specific considerations for overweight individuals.
Individuals should bear these considerations in mind in order to help reduce their risk of complications.
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sedation, general anesthesia, and/or a nerve block. He or
she may also recommend different monitoring devices to
help keep you safe during the procedure. Regardless of
the type of anesthesia, there are specific challenges for
you and your anesthesiologist if you have obesity.
Procedures such as intravenous (IV) placement, nerve
blocks, and epidurals may be more difficult because in
individuals with obesity it can be difficult to locate the
anatomical structures (e.g., veins) needed to complete
the task. The best advice for you is to be patient, and if
you are getting uncomfortable, ask for a break. Your
anesthesiologist wants to make sure you are at ease
before surgery, so he or she will usually be willing to give
you time to catch your breath if a procedure is difficult.
If you are going to be under general anesthesia, there is
an increased risk of difficulty with placement of a
breathing tube. Most hospitals have several different
devices that can help with the placement of breathing
tubes, but if you have ever been told that you are a
“difficult intubation,” it is extremely important to tell
your anesthesiologist and surgeon prior to the surgery.
You may be asked to take an antacid prior to surgery.
Since individuals with obesity may have a higher risk of
aspiration (inhalation of stomach contents) during
intubation, this will neutralize stomach acid. Another
good practice is to bring your CPAP machine with you
when you come to the hospital. If you are going to be
under sedation, your anesthesiologist may have you use
it during the operation, and it is important to use it after
surgery when you are waking up from anesthesia.
POSTOPERATIVE CONSIDERATIONS
Once the operation is over, there are still some
important considerations. Your anesthesiologist and
surgeon will want to maximize your breathing capacity
because during the time spent under anesthesia, the
lungs can become compressed. In order to do this, you
may use a device called an incentive spirometer to help
expand your lungs. If you are still in significant pain,
your anesthesiologist may recommend other techniques
to combat your pain, such as nerve blocks or epidurals,
in order to decrease the need for sedating pain
medications. Finally, there is an increased risk of
developing a blood clot, so you will likely receive blood-
thinning shots and be encouraged to get out of bed as
soon as possible.
FINAL THOUGHTS
As you can see, going under anesthesia can be safe, as
long as you are aware of the risks and work with your
doctors to try to minimize risk impact. If you have any
specific questions or concerns, you should contact your
anesthesiologist before the day of surgery to address
them so you can be confident and feel safe on the day of
surgery.
REFERENCES
1. Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking
obesity to insulin resistance and type 2 diabetes. Nature.
2006;444:840–846. BMI
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Dr. Fullum: Jamie, congratulations on the early success
of your Billion Pound Blitz Campaign and the Put Up
Your Dukes Foundation. What made you decide to
become a gladiator against obesity and obesity-related
diseases?
Jamie: There’s an old saying that is absolutely true: “Your pain
is your passion.” That is truly the case for me. Despite at one
time being one of the top athletes in the world, I struggled all
my life with excess weight. Watching seven former teammates
to date die from the diseases of excess weight was the catalyst
for establishing the Put Up Your Dukes Foundation whose sole
charge is to fight against the diseases of excess weight.
Dr. Fullum: Your personal story is inspiring. If you don’t
mind, please share a little more about your own battle
with obesity.
Jamie: I played 10 years in the NFL and in my retirement, my
weight incrementally went up to the point that I was a happy
meal over 400 pounds. Watching other teammates die
contributed to my angst as I realized that it was only a matter
of time before I would encounter an adverse event.
Dr. Fullum: As a professional athlete and sports
celebrity, you are in a unique position to reach millions
who suffer from obesity. How do you plan to make a
difference?
Jamie: While there is much work to do, the Put Up Your
Dukes Foundation was successful in the inclusion of bariatric
solutions in the menu of services for former NFL players. We
have also created the following solutions:
• Chachersize—an exercise program based on Line
Dancing. Learn more at www.chachersize.com
• Chachersize ABC (Academic Burst Curriculum)—
improves student focus while increasing physical fitness.
Learn more at www.chachersizeabc.com
• Ask The Fat Doctors—The Fat Doctors online webcast,
of which you, Dr. Fullum, are an invaluable part, shines a
clinical spotlight on the diseases of excess weight in a
multifaceted and entertaining way. Learn more at
www.askthefatdoctors.com
• Billion Pound Blitz—a solution that utilizes incentive with
high-profile celebrity brands. Lern more at
www.billionpoundblitz.com
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Copyright © 2012 MMC18 BMI Body • Mind • Inspiration—Summer 2012
FIGHTING
OBESITY ONE
CALORIE AT
A TIMEAn Interview with NFL
Veteran Jamie D. Dukes
by Terrence M. Fullum, MD, FACS
About JAMIE D. DUKES
Jamie is a 10-year NFL Veteran and current host on NFL
Network. Jamie and his wife, Angela, are the founders of the
“Put Up Your Dukes Foundation,” whose mission is to fight
the deadly links to the diseases of excess weight.
In June 2010, the Put Up Your Dukes Foundation launched the
Billion Pound Blitz (BPB), a program that challenges
individuals to be accountable for their physical and fiscal
health needs.The BPB provides access to celebrities and
professional Athletes for individuals who achieve success. To
accomplish this goal, tools like “Chachersize” and “Ask The
Fat Doctors” were created as a fun way to engage
participants.
Dukes, along with Falcons owner Arthur Blank and other
current NFL players, partnered with United States Senate
representatives to reintroduce the Fitness Integrated with
Teaching (FIT) Kids Act. The FIT Kids Act works to combat
childhood obesity by strengthening physical education
programs throughout the country.
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Copyright © 2012 MMC 19BMI Body • Mind • Inspiration—Summer 2012
Dr. Fullum: I recently had the incredible opportunity to
work with you on the “Ask the Fat Doctor” podcast and
the City of Atlanta’s Seniors “Healthier You” campaign.
These are grass roots movements that you have
initiated. What is your strategy and what are your
goals?
Jamie: The “Healthier You” is a national seniors strategy
designed to improve the quality of life for seniors, not only
physically with our Boomers Chachersize, but also
educationally as we provide them with relevant information
that is germane to their wellbeing. Atlanta was the kick off and
the goal is to expand to the following areas in the next 18
months: New York/New Jersey; Washington, DC/Baltimore;
Raleigh/Duham; South Florida; Dallas; and Los Angeles.
Dr. Fullum: If someone reading this article wants to get
involved, how can he or she do it?
Jamie: Contact us at www.puydf.org.
Dr. Fullum: Although there are successful long-term
surgical treatments for obesity, the demand far out
numbers the supply. According to the Center for
Disease Control (CDC), there are over 20 million
people in the United States who qualify for weight loss
surgery, but we are only performing approximately
115,000 surgeries yearly. It is obvious that the only
viable cure for obesity is prevention. If you were the
surgeon general, how would you attack the obesity
epidemic?
Jamie: Create3, a national marketing effort with the fast food
industry extols the healthier choices on their menus. The
reality is Americans eat an average of 3.5 times per week at
fast food establishments, not only for taste, but for economics.
Fast food restaurants have healthy choices and we need to
redirect consumers to the healthy part of the menu.
Dr. Fullum: America needs to change as a society if we
are going to cure obesity and continue to live longer
and healthier lives. How will your grass roots campaign
affect such a change?
Jamie: One calorie at a time… BMI
Dr. Terrence M. Fullum is Associate Professor of Surgery at Howard University College of Medicine,
Chief, Division of General Surgery and Chief, Division of Minimally Invasive and Bariatric Surgery at
Howard University Hospital in Washington, DC. In addition, Dr Fullum is Medical Director of the
Howard University Center for Wellness and Weight Loss Surgery.
“I played 10 years in the NFL and inmy retirement, my weightincrementally went up to the pointthat I was a Happy Meal over 400pounds. Watching other teammatesdie contributed to my angst as Irealized that it was only a matter oftime before I would encounter anobesity-related event.”
The Dukes family (left to right: Joi, Jamie Jr., Jamie Sr., Angela)
Jamie Dukes and his team leading an exercise class
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Copyright © 2012 MMC20 BMI Body • Mind • Inspiration—Summer 2012
INTRODUCTIONAdding volume is one of the last things one would
think a patient who has undergone massive weight loss
would desire; however, massive weight loss actually leads
to significant deflation of the skin from head to toe, and
this deflation is most apparent in the face, neck, breasts,
and buttock. Following massive loss of volume (fat),
these parts of the body can take on an appearance best
described as a deflated balloon—not the fit, attractive
physique one would hope to achieve following significant
weight loss. Volume lost in specific body regions may be
restored, however, in the massive weight loss patient
through the use of fillers, tissue grafting, local tissue
rearrangement, and prosthetics to achieve fullness,
shape, and a positive body image.
THE FACEChanges in facial skin due to massive weight loss may
mimic the aging process, which visually can add years to
a face, even in the most youthful individual. As the
volume of the face decreases, the skin becomes more lax
and the facial folds more pronounced, the skin of the
brows may descend into the eyes causing fullness and
skin excess of the upper lids, cheeks may descend
causing an elongation of the lower eyelids, the jawline
may appear more blunted and jowled, and most notably,
the neck may appears more full with lack of definition
between the neck and the jaw.
Cosmetic treatment includes injection of fillers, fat
grafting, lifting of tissues with suspension in face, and
necklifting.1 These treatments may be performed as
isolated procedures or may be used together to
complement each other in achieving more comprehensive
correction.
Fillers. Most fillers are off-the-shelf products and
include those made with hyaluronic acid (e.g., Juvederm®
[Allergan, Irvine, California], Perlane® [Medicis
Aesthetics, Scottsdale, Arizona], and Restylane® [Medicis
Aesthetics, Scottsdale, Arizona]) or poly-L-lactic acid
(e.g., Sculptra®, Sanofi-Aventis, Bridgewater, New
Jersey).
Hyaluronic acid products are indicated for correction
of moderate-to-severe facial wrinkles and folds and can
be used to blunt pronounced folds between the nose and
lip (nasolabial folds) and to plump thinned lips that have
frowning corners of the mouth due to loss of volume
(Figure 1).
The poly-L-lactic acid products are used to plump up
VOLUMETRY:
A New Dimension in
Contouring the
Massive Weight Loss
Individual
by Michele A. Shermak, MD, FACS
Dr. Shermak is Associate Professor of Plastic Surgery, Johns Hopkins School of Medicine
in Baltimore, Maryland.
Individuals who undergo massive weight loss may become volumetrically challenged. In a landscape of skin excess andoverhang, significant tissue deflation may develop, particularly in the face, breast, and buttock area. Strategies for volumetricreconstruction and enhancement depend on the use of commercial injectible fillers, fat grafting, flap rotation, and shifting oftissue from a site of excess to one of deficiency.
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flattened, descended cheeks and the areas around the
eyes, and treating these areas subsequently can lift the
lower part of the face, which improves the overall
appearance.
Fat grafting. An individual’s own fat may also serve
as the filler, and this fat in volumes of approximately 10
to 30cc can be used to fill the nasolabial folds and lips,
either as a stand-alone procedure or in combination with
facelifting (Figure 2). Fat grafting is a small operative
procedure that can be combined into larger body
contouring procedures. Fat is harvested from the
abdomen or thigh, concentrated with removal of fluid
components of the aspirate, and transferred into the
face. The grafted fat will incorporate almost completely
into the recipient site. When there is an extreme degree
of volume loss and surgical facelifting is required, fat
grafting can easily be incorporated into the procedure.
THE BREAST
The breast of a woman who has undergone massive
weight loss may incur significant deflation with ptosis,
medial displacement of the nipple, areolar complexes,
and sliding down of the inframammary folds (IMFs). As
the fatty component of the breast tissue decreases, the
overall volume of the breast decreases.
Corrective options for the breast include breastlift
(mastopexy), augmentation with fat grafting,
augmentation with breast implants, and combinations of
these procedures (Figure 3). Most women pursue a
breastlift, with removal and tightening of the skin around
the existing breast tissue. The underlying breast tissue
may be rearranged to transfer redundant tissue from
under the arm to the central breast area as an auto-
augmentation, and the tissue is stabilized to avoid
displacement and descent2 (Figure 4).
Fat grafting is a new addition to the breast
augmentation armamentarium, and hundreds of
milliliters of purified fat can be transferred into the
breast tissue, subcutaneous tissue, and pectoralis
muscles. This is a new technique, and there is not much
data yet available on it. In 2010, Parrish and Metzinger3
stated that the available literature on this procedure
consists primarily of case reports and case series, with
no controlled trials. Therefore, outcomes thus far have
not been measured in a standardized way. Concerns have
been raised that the placement of mature adipocytes and
adipocyte-derived stem cells into the hormonally active
environment of the breast may potentiate breast cancer,
but there have been no clinical trials yet that investigate
this possibility, and a consensus regarding the basic
science is still developing.
THE BUTTOCK
An individual who has undergone massive weight loss
has increased vertical length between the upper back
and the buttock, an area of tissue that was previously
expanded with subcutaneous fat. This span of back
tissue following weight loss becomes deflated, and
redundant tissue buries the buttocks below it. Many
weight loss individuals pursue belt lipectomies with
abdominal panniculectomy or abdominoplasty to treat
the abdomen, continuous with a backlift to raise the
Copyright © 2012 MMC 21BMI Body • Mind • Inspiration—Summer 2012
FIGURE 1. This individual sustained massive weight loss. She was unhappy with theappearance of her face after weight loss (A). She underwent a facelift with plicationof the muscles and skin tightening. After surgery, she achieved greater fulness of thelips and nasolabial folds with Restylane injection (B).
FIGURE 2. A woman before (A) and after (B) fat grafting og the nasolabial folds andmouth in conjunction with a facelift.
FIGURE 2. This is a woman in her 30s who lost greater than 50-percent excessbody weight, leading to significant volume loss and sagging of her breasts (A). Shehad a mastopexy combined with augmentation with breast implants to correct herpresentation (B). She is three years out from her surgery.
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buttock and the outer thigh. In some cases, there is so
much redundant back tissue, that it can be recycled to
create an autogenous implant for the buttock (Figure 5).
Provided circulation by the superior and inferior gluteal
arteries, autologous gluteal augmentation with an
individual’s own tissue provides a solution to the
deflation of the buttock.4 While gluteal implants can be
used to treat deflation of the buttocks, in this author’s
opinion, harvesting the material for augmentation
directly from the individual’s own body and injecting it
into the gluteal muscles and subcutaneous fat should be
considered as an option before synthetic implants.
CONCLUSION
Individuals who have sustained massive weight loss
may seek corrective surgery for excess or hanging skin
due to volume loss. The face and neck, breast, and
buttock areas are particularly susceptible to volume
deficiency after massive weight loss. Options include use
of fillers; autogenous tissue, including grafts and flaps;
and implants in order to add volume necessary to achieve
a youthful, shapely body.
REFERENCES
1. Bucky LP, Kanchwala SK. The role of autologous fat and
alternative fillers in the aging face. Plast Reconstr Surg.
2007;120(6 Suppl):89S–97S.
2. Shermak MA, ed. Breast and Body Contouring Surgery
Atlas, First Edition. New York: McGraw Hill, 2011.
3. Parrish JN, Metzinger SE. Autogenous fat grafting and
breast augmentation: a review of the literature. Aesthet
Surg J. 2010;30(4):549–556.
4. Centeno RF, Mendieta CG, Young VL. Gluteal contouring
surgery in the massive weight loss patient. Clin Plast
Surg. 2008;35(1):73–91; discussion 93. BMI
FIGURE 4. This woman in her 40s lost greater than 50 percent excess body weight,leading to significant volume loss and sagging of her breasts (A,B). She did notdesire implants. She had a mastopexy with augmentation of the breast tissue rotated in from the axillary fullness (C,D).
FIGURE 5. This woman lost greater than 50-percent excess body weight, leading tosignificant volume loss and sagging in her buttock region. The lower back isexcessive and buries her buttock under it (A). She had autologous glutealaugmentation designed from the lower back tissues that would otherwise bediscarded. The buttock is far more full and visible (B). Functionally, the patient ismore comfortable sitting as well.
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