11/2/2012 1 The Changing Body After Bariatric Surgery – Plastic Surgery & Other Options Al Aly, MD, FACS Professor of Plastic Surgery Director of Aesthetic Plastic Surgery University of California Irvine Overview Why I specialize in MWL Plastic Surgery Educate you about “Body Contouring after Massive Weight Loss” Questions and Answers
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The Changing Body After Bariatric Surgery – Plastic Surgery & Other
Options
Al Aly, MD, FACSProfessor of Plastic Surgery
Director of Aesthetic Plastic Surgery
University of California Irvine
Overview
� Why I specialize in MWL Plastic Surgery
� Educate you about “Body Contouring after Massive Weight Loss”
� Questions and Answers
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I have been doing MWL Plastic Surgery longer than
anybody in the world
How can that be?
A Little History
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Bariatric Surgery was fathered at the University of
Iowa back in the 60s and 70s
by a Dr. Mason
But it was not popular because of lack of refinement till 2000
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The field of body contouring after massive weight loss did not exist
then
A few places had MWL patients and Iowa was one
of them
Because of Mason
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When I started my practice at the University of Iowa there was a back log of
MWLPs
Forced by patient demand
Invented or Developed plastic surgery procedures utilized world wide today
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Dr. Aly published the first textbook
ever written on
the subject
“The BIBLE”
It has been sold or illegally copied all over
the world
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List of countries where I lectured and/or operated
� US (extensively)� Canada� Costa Rica� Brazil� Argentina� Mexico� Colombia� Dubai� Qatar� New Zealand
� Saudi Arabia� Germany� Spain� Turkey� Portugal� Russia� Kuwait� Egypt� Belgium� India� Australia
I am passionateand
I care very much
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What happens with weight loss after obesity?
The skin acts like a balloon, it expands
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When people lose weightSome patient’s balloon returns
to normal size
What happens when you gain weight then lose it?
Some patients’ skin expands past its limits and loses its elasticity
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They end up with Loose
excessive skin
Most MWLP will not go back to normal after
their weight loss
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Presentation of the MWLP is extremely variable
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If all treated the same wayResults are inferior
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Factors That Affect RESULTS
�Weight or BMI at presentation
�Fat deposition pattern
�Quality of skin-fat envelope
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Apple Pear
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Mind-Set at Presentation
Dear Dr,I use to weight 350 pounds and felt extremely bad about it, my health was awful, I could hardly get around. . . I had gastric bypass surgery 2 years ago and lost 200 pounds. . . Unfortunately, I still look and feel fat. I have worked so hard to get to where I am but I feel that it might have been all for nothing. Can you help me?
I still look and feel
fat
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Four Major Regions
�Lower trunk
�Upper arms
�Thorax
�Thighs
Massive weight loss patients have
circumferential lower truncal excess in the shape
of an inverted cone
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The Inverted Cone
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Treatment Options
�“T” shaped lipectomy
�Abdominoplasty
�Circumferential lipectomy
T Shaped Panniculectomy
May lead to bizarre contours
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T Shaped Panniculectomy
Even when done well has no effect on the sides or back
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� PostOp: False
� Age: 39
� PostOp: False
� Age: 39
No back or buttocks improvements
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Tummy Tuck
�Ideally treats�Mild excess belly fat
�Excess belly skin
�Belly laxity
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Bulge or “Dog Ear”
Tummy Tuck only in a massive weight loss patient
No back or buttocks improvements
Tummy Tuck only in a massive weight loss patient
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Bulge or “Dog Ear”
Tummy Tuck only in a massive weight loss patient
No back or buttocks improvements
Tummy Tuck only
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Rehabilitation of the lower trunk in the
massive weight loss patient most often
requires circumferential treatment
A Tummy Tuck is like a conventional weaponA BELT LIPECTOMY
is like a NUCLEAR WEAPON
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= TensionTension=Improvement
Tension =
Improvementaway from closure
=Improvement
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0 Tension
No back or buttocks skin tightening
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Why Circumferential?
� Eliminates� Pubic area excess
� Tummy bulges and aprons
� Outer and lower back excess
� Buttocks droopiness
� Lifts the outer and front thighs
� Increases buttocks definition
� Creates a waist
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Pubic Area
Abdomen
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Outer & Lower back
Waist
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Buttocks
Buttocks
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Front & Outer Thighs
Belt lipectomyLower body liftCentral body lift
Circumferential abdominoplastyTorsoplasty
BODY LIFT
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Body Lifts Are Not All The Same
Approaches to The Trunk
Lower Body Lift
Belt Lipectomy
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Lower body lift = LowBelt lipectomy = high
Lower body lift = Low
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Belt lipectomy = high
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The cinching leads to “an illusion”of increased projection
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Criteria For Surgery
� Medically healthy
� Psychiatric stability
� Non-smoker
� Reduced intra-abdominal content
� Stable weight for ~3 to 6 months
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Heroic efforts to lose weight are counter productive
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Belt Lipectomy/Body lift
� PostOp: False
� Age: 48
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Belt Lipectomy
�3 to 6 hours
�Requires two turns in the OR
�Recovery- 3 to 6 weeks
�Should be approached as a “major life event”
Massive Weight Loss
�Generally, results correlate with the patient’s BMI at surgery
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High BMI
Expected Results
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Expected Results
Intermediate BMI
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Expected Results
Near ideal BMI
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Upper arm excess in the
MWLP
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� PostOp: False
� Age: 48
In massive weight loss patients the excess crosses the axilla (armpit), onto the lateral chest wall
Thus, upper arm reduction or Brachioplasty must account for that
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General Physical Presentations
�Upper Arms�The excess crosses the axilla
�The excess is the posterior axillary fold
�Different amounts of retained fat
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� PostOp: False
� Age: 40
The Posterior Axillary fold
Presentation
� If greatly deflated – ideal
� If significantly inflated – preliminary liposuction & staged excision
� If intermediate – decision has to be made with patient
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Brachioplasty in the MWLP SHOULD
CROSS THE AXILLA and follow the defect
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� PostOp: False
� Age: 40
The Double Ellipse Technique
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Brachioplasty Results
Why Doesn’t The Traditional “T”Approach Work
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� PostOp: False
� Age: 25
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Upper Arm Complications
� Seroma
� Lymphocele/lymphedema
� Inability to close the arm
� Bad scarring
� Infection/Bleeding
� Nerve compression/sensory loss
Upper Body Lifts treats
Entire Chest Deformity
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Thorax
The Normal Position
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The Normal Position
Thoracic Deformities
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General Physical Presentations
� Thorax-upper truncal subunit� An analogy - expansion and then
deflation of a lamp shade that is tethered at two points
� Horizontal excess – extension of the upper arm excess
� Vertical excess
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Upper Body Lift Results
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� PostOp: False
� Age: 22
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� PostOp: False
� Age: 24
� PostOp: False
� Age: 24
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� PostOp: False
� Age: 25
� PostOp: False
� Age: 25
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Thigh Reductions
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� PostOp: False
� Age: 25
� PostOp: False
� Age: 32
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Thigh Reduction in the MWLP
�Mostly a vertical excision
�Occasionally a horizontal component
�This approach follows the defect
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Insurance does not cover much past the hanging belly
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Consider working on finance EARLY
should you need it
Be realistic in your expectations
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Greater rate of complications
BEWARE &
BE AWARE
Body contouring after MWL is highly specialized
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Be a WISE CONSUMER when it comes to plastic
surgery after MWL
Summary
�Skin acts like a balloon
�Body lifts are required
�Body lifts are not all the same
�Arm reduction to chest wall
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Summary
�Upper body needs an UBL
�The thighs are hard
�Realistic expectations
�Higher rate of complications
Summary
�Insurance doesn’t cover
�So PLAN
�Be a wise consumer
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Plastic Surgery can be a
LIFE TRANSFORMATION
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I still look and feel
fat
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“Bariatric surgery gave me back my life, the plastic
surgery that I had allowed me to enjoy it”
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Al Aly, MD, FACS
End
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