528208
research-article2014
AESXXX10.1177/1090820X14528208Aesthetic Surgery JournalConstantine et al
Body Contouring
The Effect of Massive Weight Loss Status,
Amount of Weight Loss, and Method of
Weight Loss on Body Contouring Outcomes
Aesthetic Surgery Journal
2014, Vol. 34(4) 578­–583
© 2014 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
http://www​.sagepub.com/
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DOI: 10.1177/1090820X14528208
www.aestheticsurgeryjournal.com
Ryan S. Constantine, BA; Kathryn E. Davis, PhD; and
Jeffrey M. Kenkel, MD
Abstract
Background: The impact of massive weight loss (MWL) on body contouring procedures and outcomes has not been firmly established in the literature.
Objective: The authors investigate the correlations between MWL status, the method of achieving MWL, and the amount of weight lost with woundhealing complications after body contouring procedures.
Methods: The charts of 450 patients (124 of whom had undergone MWL) who underwent body contouring procedures including abdominoplasty,
brachioplasty, thighplasty, breast mastopexy/reduction, lower bodylift, bodylift, buttock lift, and liposuction were reviewed. MWL patients were classified
as having achieved weight loss through diet and exercise, gastric banding or sleeving, or gastric bypass. Postoperative complication data were collected,
including cases of infection, delayed wound healing, seroma, hematoma, dehiscence, and overall wound problems. Odds ratios (OR) were estimated
using 4 multivariate logistic regression models.
Results: MWL status was a significant predictor of wound problems (OR, 2.69; P < .001). Patients with 50 to 100 lbs of weight loss did not have a
significantly increased risk of wound problems (OR, 1.93; P = .085), while patients with over 100 lbs of weight loss did (OR, 3.98; P < .001). Gastric bypass
(OR, 3.01; P = <.001) had a higher risk correlation than did diet and exercise (OR, 2.72, P = .023) or restrictive bariatric surgery (OR, 2.31; P = .038) as
a weight loss method. Patients who lost over 100 lbs demonstrated increased risk of complications if they had gastric bypass or restrictive procedures.
Conclusions: MWL was a significant risk factor for wound complications in the body contouring population. Method and amount of weight loss were
also significant factors in predicting complications.
Keywords
body contouring, body sculpting, liposuction, abdominoplasty, bodylift, massive weight loss, risks, complications, malnutrition, wound healing
Accepted for publication September 24, 2013.
The rising rate of obesity over the past few decades is
among the most pervasive health trends; currently, more
than one-third of Americans are considered obese.1
Associated comorbidities such as diabetes mellitus, cardiovascular disease, hyperlipidemia, arterial hypertension,
and depression have increased the need for bariatric surgery to achieve weight loss and diminish the concomitant
comorbidities in this patient population effectively and
safely.2 Approximately 101 000 gastric bypass, gastric
banding, and gastric sleeve procedures were performed in
the United States in 2011, reflecting the prevalence of obesity within the population.3
Massive weight loss (MWL) following bariatric surgery
often leads to skin excess; 68% to 85% of postbariatric
surgery patients desire body contouring surgery to remove
the excess,4,5 which represents an area of steady growth
From the Department of Plastic Surgery, University of Texas
Southwestern Medical Center, Dallas, Texas.
Corresponding Author:
Dr Jeffrey M. Kenkel, Professor and Vice-Chairman, Department of
Plastic Surgery, University of Texas Southwestern Medical Center,
1801 Inwood Rd, Dallas, TX 75390, USA.
E-mail: [email protected]
Constantine et al579
within plastic surgery. Procedures such as abdominoplasty
have increased over 360% in the last 16 years.6 Body contouring procedures are not without risk, as surgery time
can be prolonged and relatively high complication rates
have been cited in the literature.7,8 MWL patients also carry
unique risks because of redundant skin, nutritional deficiencies, and overall metabolic differences, especially as
these factors relate to the wound-healing process.9
In this study, we sought not only to distinguish how
outcomes were affected by MWL status among the entire
body contouring patient population but also further analyze the risk of the various methods of achieving MWL.
Methods
Study Design
A UT Southwestern institutional review board–approved
retrospective chart review was performed of 1801 complex
plastic surgical cases performed at a single academic medical center between January 1, 2008, and January 31, 2012.
Relevant information was abstracted from patient charts
and hospital records, and a database was constructed to
capture a broad range of procedures with long operative
times, including some combined surgeries. Patients
included in the analysis received abdominoplasty, brachioplasty, thighplasty, breast mastopexy/reduction, lower
bodylift, bodylift, buttock lift, and/or liposuction. Patients
who returned to the study site for additional body contouring procedures at multiple dates were selected only for
their first encounter to reduce statistical bias. Body contouring procedures combined with hernia repair were
excluded. Of the 1801 cases included in the database, 450
cases met the inclusion criteria. Of these 450 cases, 407
patients were women and 43 were men.
Preoperative patient characteristics, including sex, age,
body mass index (BMI; kg/m2), MWL status, method of
weight loss, and common comorbidities associated with
postoperative complications were included in the analysis.10,11 Patients were considered to have undergone MWL
if they had achieved a weight loss of 50 lb or more. Method
of weight loss was categorized as gastric bypass, restrictive
(which included laparoscopic band and gastric sleeve procedures), and unspecified (which included patients lacking a specific history regarding their weight loss method).
Postoperative complications were assessed and noted in
clinical progress notes by attending physicians and
included infection, delayed wound healing, seroma, hematoma, dehiscence, and overall wound problems, which is
inclusive of all of the aforementioned complications. These
complications were then abstracted from the chart review
and included in the larger database.
Patient demographics were summarized as a mean and
standard deviation for continuous variables and as a
percentage for categorical variables. Univariate analyses
were utilized to compare patient characteristics and comorbidities, and significant factors were selected for further
analysis. Odds ratios were estimated using 4 multivariate
logistic regression models: (1) a base model including
MWL status, (2) a model adjusting for the amount of
weight lost, (3) a model adjusting for the method used to
achieve MWL, and (4) a model measuring the interaction
between method of weight loss and the amount of weight
lost. While history of myocardial infarction, coronary
artery disease, chronic obstructive pulmonary disease, and
deep venous thrombosis were included in the original
models, they were eventually omitted from further statistical consideration. Statistical significance was assigned if P
values were less than .05. All data analysis was conducted
with Stata/SE Version 12.0 (StataCorp, Inc, College Station,
Texas) statistical software.
Results
The average age of the study population was 45.4 years
(range, 16-79 years). Overall patient demographics and
complication rates are summarized in Table 1. The complication rate for the study population was 19.1% with an
average follow-up time of 6 months. Of the 450 body contouring cases, 124 were classified as MWL patients, and
univariate analyses comparing MWL patients with nonMWL patients are summarized in Table 2. The methods of
achieving weight loss and corresponding wound problem
rates are summarized in Table 3.
Multivariate logistic regression using the base model
showed that MWL status was a statistically significant (odds
ratio [OR], 2.69; P < .001) predictor of wound problems in
body contouring patients (Table 4). A second logistic regression model (Table 5) estimating the effect of the amount of
weight loss (50-100 lb and 100+ lb) demonstrated a statistically significant result for those in the 100+-lb category (OR,
3.98; P < .001) and, for the 50- to 100-lb group, a result that
approached statistical significance (OR, 1.93, P = .085). A
related model demonstrated an odds ratio of 1.0094 (P <
.001) per each additional pound lost.
The method of weight loss was also analyzed in a multivariate logistic regression that regressed on each respective method: gastric bypass, restrictive (including gastric
banding or gastric sleeve), and diet and exercise. All 3
methods demonstrated statistically significant differences
regarding wound problems from the non-MWL population.
Gastric bypass (OR, 3.01; P = .002) demonstrated a higher
odds ratio than either diet and exercise (OR, 2.72; P =
.023) or restrictive bariatric surgery (OR, 2.31; P = .038).
These data are summarized in Table 6.
The interaction between the method of weight loss and
the amount of weight loss was explored in the final multivariate logistic regression (Table 7). Although the regression
580
Aesthetic Surgery Journal 34(4)
Table 1. Patient Demographics (450 Patients)
Table 2. Univariate Analysis: No MWL vs MWL
Value
%
Average ± SD
Sex (male)
43/450
9.56
Age >45 y
213/450
47.3
BMI ≥30
115/450
MWL
124/450
No MWL
MWL
P Value
Sex (male)
36/326
7/124
.082
45.4 ± 12.3
Age >45 y
155/326
58/124
.884
25.6
27.2 ± 5.10
BMI ≥30
74/326
41/124
.024a
27.6
Smoker
18/326
8/124
.706
9/326
15/124
<.001a
62/326
30/124
.224
Smoker
26/450
5.78
Diabetes
Diabetes
24/450
5.33
Hypertension
Hypertension
92/450
CAD
1/326
1/124
.476
2/326
0/124
.382
43/326
21/124
.309
0/326
1/124
.105
20.4
CAD
2/450
0.44
MI
MI
2/450
0.44
Other cardiac
COPD
Other cardiac
COPD
64/450
14.2
1/450
0.22
Other pulmonary
20/326
14/124
.064
Other pulmonary
34/450
7.6
Renal diseases
10/326
3/124
.714
Renal diseases
13/450
2.89
Cancer
32/326
4/124
.021a
Cancer
36/450
8.00
DVT
2/326
3/124
.103
5/450
1.11
Wound problem
48/326
38/124
<.001a
Infection
6/326
8/124
.012a
5/326
13/124
<.001a
DVT
Wound problem
86/450
Infection
14/450
3.12
Dehiscence
Dehiscence
18/450
4.00
Erythema
16/326
16/124
.003a
Erythema
32/450
7.11
Necrosis
5/326
4/124
.252
Necrosis
9/450
2.00
Seroma
17/326
6/124
.871
Seroma
23/450
5.11
Hematoma
1/326
4/124
.008a
5/450
1.11
Delayed wound healing
4/326
8/124
.002a
12/450
2.67
Hematoma
Delayed wound healing
19.1
BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary
disease; DVT, deep venous thrombosis; MI, myocardial infarction; MWL, massive weight loss.
estimates that the method of weight loss and a weight loss
of 50 to 100 lb did not demonstrate a statistically significant
risk, the interaction between 100 lb or more lost and the
method of weight loss was statistically significant, except in
the diet and exercise population.
Discussion
The connection between MWL and body contouring surgery
has been the subject of an amalgam of original research as
well as advisories regarding the evaluation and treatment of
this patient population.12-15 Our analysis indicated that MWL
patients have a statistically significant increased risk of
developing wound complications in the postoperative period
compared with the non-MWL population. However, this
BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary
disease; DVT, deep venous thrombosis; MI, myocardial infarction; MWL, massive weight loss.
a
Result is statistically significant as P < .05.
conclusion has been debated in the body contouring literature; Vastine et al16 and Kerviler et al17 indicated that bariatric surgery did not correlate with an increased risk of
complications in body contouring procedures, while Greco
et al12 and Staalsen et al18 published results to the contrary.
Despite their differing conclusions, these studies all had a
comparatively small sample size, and statistical power consequently may have been hampered.
Our analysis showed an almost 2-fold increased risk of
complications conditional on the amount of weight lost in
the MWL patient. This finding was corroborated by Coon
et al,19 who found that maximum BMI and change in BMI
were associated with developing wound complications, as
change in BMI can be associated with the amount of
weight lost. Our study would have benefited from similarly
utilizing change in BMI as a variable for analysis; however,
Constantine et al581
Table 3. Method of Weight Loss (450 Patients)
Table 5. Multivariate Logistic Regression: 50- to 100-lb Loss vs
100+-lb Loss
Value
%
51/124
41.1
17/51
33.3
40/124
32.2
Wound problem
12/40
30.0
Diet and exercise
33/124
26.6
9/33
27.3
Gastric bypass
Wound problem
Restrictive band/sleeve
Wound problem
Variable
Table 4. Multivariate Logistic Regression: Massive Weight Loss Status
Variable
Odds Ratio
95% CI
P Value
MWL
2.69
1.60-4.52
<.001a
Sex (male)
1.20
0.51-2.82
.674
Age >45 y
1.26
0.74-2.15
.386
BMI ≥30
1.45
0.82-2.55
.200
Smoker
0.13
0.02-1.02
.053
Diabetes
0.38
0.10-1.42
.151
Hypertension
1.50
0.79-2.85
.211
Other cardiac
0.78
0.36-1.69
.521
Other pulmonary
0.65
0.24-1.76
.397
Renal diseases
1.67
0.39-7.19
.493
Cancer
0.53
0.17-1.60
.260
BMI, body mass index; CI, confidence interval; MWL, massive weight loss.
Result is statistically significant as P < .05.
a
due to constraints in the data set, this metric was unavailable. Furthermore, our study was unable to compare complication rates among the various body contouring
procedures due to a relatively small sample size that would
have produced statistically unreliable results. While larger
procedures like lower bodylift would ostensibly have
higher complication rates than strictly liposuction, for
example, the procedures analyzed all fall under the purview of “body contouring” as it is defined in the literature
and textbooks and were thus studied as a whole.20,21
Differences between these body contouring procedures,
however, should be studied in the future.
The method of achieving MWL proved an indicator in
predicting complication rates for body contouring surgery.
Our data indicated that regardless of the method of MWL,
these patients demonstrated increased risk for wound
problems compared with the non-MWL patient. Gastric
bypass patients, however, had a greater risk than either the
Odds Ratio
95% CI
P Value
MWL (50-100 lb)
1.93
0.91-4.06
.085
MWL (100+ lb)
3.98
1.93-8.23
<.001a
Sex (male)
1.16
0.49-2.75
.731
Age >45y
1.17
0.68-2.04
.588
BMI ≥30
1.48
0.82-2.67
.194
Smoker
0.13
0.02-0.97
.053
Diabetes
0.44
0.11-1.77
.245
Hypertension
1.59
0.82-3.08
.172
Other cardiac
0.78
0.35-1.73
.536
Other pulmonary
0.74
0.27-2.02
.552
Renal diseases
1.45
0.33-6.42
.628
Cancer
0.56
0.18-1.70
.306
BMI, body mass index; CI, confidence interval; MWL, massive weight loss.
a
Result is statistically significant as P < .05.
restrictive bariatric surgery population or the diet and exercise population. The current literature is sparse regarding
the correlation of restrictive bariatric surgeries and outcomes for body contouring surgeries but has focused on
differences between weight loss achieved through dietetic
means and gastric bypass.16-18 Gusenoff et al22 noted that
there was no significant difference in outcomes between
patients treated with bariatric procedures and patients
who dieted and exercised.
A trend relating the amount of weight lost and the
method of weight loss emerged in our study, as MWL
below 100 lb was not a significant risk factor, no matter the
method. Weight loss greater than 100 lb indicated significant risk associated with both restrictive bariatric procedures and gastric bypass, but not diet and exercise. The
diet and exercise group with more than 100 lb lost included
only 4 patients; thus, a larger sample size within this population would more accurately estimate the odds ratio.
The cause of the MWL patients’ increased risk of wound
complication may be multifactorial since nutritional deficiencies, biomechanical changes within the skin, and biological and physiologic alterations may occur within this
patient population.23 Collagen and elastic fiber differences
as well as tissue protein expression were found to be
abnormal among a population of MWL patients receiving
body contouring surgery.24 Furthermore, an examination of
wound regulatory proteins among cancer, burn, obese, and
posttransplant populations has suggested that similar
changes may occur in the MWL population.25 Among the
582
Aesthetic Surgery Journal 34(4)
Table 6. Multivariate Logistic Regression Based on Surgery Type
Variable
Odds Ratio
95% CI
P Value
Diet and exercise
2.72
1.15-6.43
.023a
Restrictive (banding/sleeve)
2.31
1.05-5.10
.038a
Gastric bypass
3.01
1.49-6.07
.002a
Sex (male)
1.20
0.51-2.83
.671
Age >45
1.25
0.73-2.13
.417
BMI ≥30
1.44
0.81-2.53
.210
Smoker
0.13
0.02-1.43
.053
Diabetes
0.38
0.10-1.02
.151
Hypertension
1.50
0.79-2.85
.213
Other cardiac
0.78
0.36-1.70
.528
Other pulmonary
0.64
0.24-1.75
.385
Renal diseases
1.68
0.39-7.30
.486
Cancer
0.53
0.17-1.60
.256
BMI, body mass index; CI, confidence interval.
a
Result is statistically significant as P < .05.
chief concerns for the postbariatric patient are nutritional
deficiencies. Nutritional intake can remain inadequate as
much as a year after surgery, and among gastric bypass
patients, intake is often under 1000 kcal/d with significant
protein deficiencies 1 year removed from surgery.26,27
While there is a mixture of nutritional deficiencies that
contribute to inadequate wound healing, addressing protein deficiencies has been targeted as a potential means of
reducing these complications, especially as protein is necessary for fibroblast formation as well as collagen production and angiogenesis.9,28 One study of body contouring
procedures after MWL utilized protein supplementation and
noted improved outcomes compared with a control group
and overall complication rates similar to nonbariatric
patients.29 Surgeons at our study site currently utilize preoperative tests for prealbumin and daily protein supplementation on average of 30 to 40 g for 1 month prior to surgery for
the MWL patient. Our results may indicate that dietary supplementation should be tailored specifically to the method
of weight loss as well as the amount of weight lost.
Conclusions
Massive weight loss status is a significant factor in determining wound complications in the body contouring population. The amount of weight lost and the means through
which this weight loss is achieved also demonstrate significant effects on predicting wound complications. Surgeons
should be cognizant of these factors when discussing body
Table 7. Interaction Effect Between Weight Loss Method and Amount of
Weight Lost
Variable
Odds Ratio
95% CI
P Value
Diet and exercise and 50-100 lb
2.40
0.86-6.71
.094
Restrictive and 50-100 lb
1.34
0.35-5.08
.671
Gastric bypass and 50-100 lb
1.96
0.47-8.15
.353
Diet and exercise and >100 lb
4.58
0.345-60.76
.249
Restrictive and >100 lb
4.84
1.60-14.58
.005a
Gastric bypass and >100 lb
3.42
1.35-8.69
.010a
Sex (male)
1.16
0.49-2.74
.735
Age >45 y
1.21
0.68-2.17
.510
BMI ≥30
1.51
0.84-2.74
.171
Smoker
0.12
0.01-1.01
.052
Diabetes
0.45
0.11-1.82
.261
Hypertension
1.56
0.80-3.03
.198
Other cardiac
0.76
0.34-1.71
.510
Other pulmonary
0.74
0.27-2.07
.568
Renal diseases
1.43
0.32-6.40
.637
Cancer
0.54
0.17-1.68
.288
BMI, body mass index; CI, confidence interval; MWL, massive weight loss.
a
Result is statistically significant as P < .05.
contouring procedures with their patients and also prepare
for surgery by utilizing protein supplementation.
Acknowledgments
The authors thank Roberto Cortez, Rachel Hein, Kendall
Anigian, Travis Miller, James Jewell, Natalie Sciano, Bhavani
Gannavarapu, Janeiro Okafor, and Alan Wang for their help
compiling the original database. They also thank Krista Hardy
and Jerzy Lysikowski for their feedback. Additionally, they
thank Debby Noble and the research support team at UT
Southwestern for their invaluable efforts.
Disclosures
Dr Davis receives research grants from Convatec (Skillman,
New Jersey), Thermotek (Flower Mound, Texas), Unilever
(London, England), Kensey Nash (Exton, PA), Andrew
Technologies (Tustin, California), TA Sciences (New York,
New York), and Innovative Therapies (Pompano Beach,
Florida). She is a paid consultant for Thermotek and Innovative
Therapies, Inc. Dr Kenkel is a paid investigator for Allergan
(Irvine, California), Erchonia (McKinney, Texas), and
Ultrashape (Irvine, California), and is on the Advisory Board
of Kythera (Calabasas, CA). Mr Constantine has nothing to
disclose.
Constantine et al583
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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