Summer 2012

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


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



Associate Editor

Kimberly B. Chesky



BMI BODY MIND INSPIRATION BUSINESS STAFF

President/Group Publisher

Robert L. Dougherty



Partner

Patrick D. Scullin



Vice President, Business Development

Joseph J. Morris



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: [email protected]

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: [email protected]

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

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persons concerned about medical symptoms or the

possiblity of disease are encouraged to seek

professional care from an approprpiate healthcare

provider.

mailto:[email protected]

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Body • Mind • Inspiration

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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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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.


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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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


http://www.jameselston.com


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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

http://www.obesityhelp.com/

http://www.bariatricu.com

http://www.drsharma.ca

http://www.abrahamverghese.com/


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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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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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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


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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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.

http://www.chachersize.com

http://www.chachersizeabc.com

http://www.askthefatdoctors.com

http://www.billionpoundblitz.com


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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

http://www.puydf.org


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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


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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