The Evaluation
Preoperative evaluation of weight, nutritional, physical, and psychiatric status is necessary prior to surgery to maximize safety. These can be evaluated with a history, physical exam, lab tests, and occasionally radiographs. It is important for patients to have proven stability near their goal weight before proceeding with body re-contouring, as further significant weight loss or weight gain could negate the effects of otherwise successful plastic surgery.
The major weight loss types of surgeries are restrictive, malabsorptive, and a combination of the two. Restrictive procedures reduce the size of the stomach and malabsorptive procedures bypass portions of the gastrointestinal tract to reduce the absorption of what is eaten. Malabsorptive procedures have significant risk for nutritional deficiencies and anemia since nutrients and vitamins are also absorbed in the gastrointestinal tract. Commonly checked labs are Albumin and Prealbumin (measurement of protein levels in blood), Hemoglobin and Hematocrit (blood counts), coagulation times (clotting ability), electrolytes, and vitamin levels (A, B complex including folate and B12, and C).
The surgical plan can be complicated since many massive weight loss patients have numerous needs of varying severity – facial / neck laxity, eyelid bags, sagging of breasts, abdomen, buttock, back, chest, thighs, arms, legs, or genitalia, and deflation of breasts or buttock. Pairing of procedures to minimize the total number of operations needed while maintaining safety is critical. Each operative plan is tailored to the patient but common combinations include:
Suspension of layers stronger and deeper than skin is critical in maximizing lift and minimizing scarring. Due to the large size of the areas treated and the potential malnutrition, complications such as fluid collections (seromas and hematomas), wound healing problems, infection, scarring, and deep vein thrombosis (DVT/PE) are more common and must be given maximum attention and may require additional prophylactic measures such as prolonged drainage and blood thinner injections at home.
