In recent years, programs of multidisciplinary management and surgical treatment of morbid obesity (Body Mass Index (BMI)> 40) have developed, resulting in a dramatic weight loss of the order of 40 at 70 kilos. The patient then regains a weight close to normal but has a global tissue collapse predominating in the hips, thighs, arms, abdomen, and breasts. This radical change in morphology obviously poses problems for patients who have to adapt to a new body pattern. The impact and beneficial effects of rapid weight loss are thus reduced. After-by-pass surgery allows still young patients to reconcile with their new morphology at the cost of one or more surgical procedures and many scars. The purpose of this article, given the increase in this type of patient, is to discuss the indications of reconstruction surgery and to specify the steps of the care.
Obesity is considered a major public health problem. The excess weight is expressed by the BMI (Body Mass Index) which corresponds to the weight in kilos divided by the height in meter squared:
BMI = BMI = weight (kg)
Size (m) 2
A subject (male or female) is in the norm with a BMI of between 18.5 kg / m2 and 24.9 kg / m2. From 30 kg / m2, it is classified as obese and beyond 39.9 kg / m2, obesity is described as morbid.
Overweight, and in particular morbid obesity, significantly increases the risk of cardiovascular disease, respiratory disease, diabetes, cholelithiasis, digestive, breast or urogenital cancer and osteoarticular problems. In addition, there are important problems of socio-occupational integration (difficulty in the labor market), personal hygiene (intertrigo, maceration) and body schema (self-confidence, relationship problems). The economic problems associated with the management of obesity-related complications therefore seem quite obvious. For all these reasons, multidisciplinary programs of medico-surgical management of obesity have been created.
At the University Hospitals of Geneva (HUG), for extreme cases, with a BMI from 40 kg / m2 after the failure of conservative treatment, gastric bypass surgery is proposed. This results in a dramatic weight loss of the order of 40 to 70 kg with improved quality of life and a significant reduction in comorbidities. Rapid weight loss after intensive dieting or surgery results in a significant morphological change resulting in particular tissue collapse in the hips, thighs, arms, abdomen, and breasts (Fig. 1). Indeed, the skin previously distended, and often poor in elastic fibers, cannot contract properly around the new volume. These patients can thus be confronted with problems of comfort (mechanical limitation in the physical activities, dress problems), of hygiene (intertrigo, macerations in skin folds), as well as on the psychological and consequently of emotional, related to the recognition of their new body diagram. The impact and beneficial effects of weight loss are thus unfortunately compromised.
The surgical program is different for each patient and depends on his age, weight, associated comorbidities and the volume of tissue to resect. It needs
frequently two or even three interventions, but it is also possible to perform the lift in one intervention by working on several areas of the body to two teams in parallel. The amount of tissue to be resected is estimated from preoperative drawings of the standing patient.
There is also a dialogue with the anesthesiologist. Indeed, the anesthesiologist must know before surgery the position of the patient during surgery and the number of sites to operate. It can thus plan the location of the various intraoperative control systems (urinary catheter, venous access, pressure cuffs, etc.). Particular attention is given postoperatively to the pains resulting from these multisite interventions and to the equilibrium of the volume.
The type of incision performed during the by-pass procedure will determine the choice of the abdominoplasty technique.2 Previously, the digestive surgeons practiced subcostal horizontal abdominal scars. Currently, these perform a mid-umbilical vertical incision. The incision of the abdominoplasty resumes, as far as possible, the medial scar of the by-pass procedure, which allows a vertical cutaneous and fatty lift. A complementary low horizontal excision makes it possible to resect the excess cutaneo-greasy inferior (suprapubic) and lateral. This leads to a final inverted T scar or “marine anchor”.
In contrast to conventional tummy tucks, tissue detachment is thus limited to a minimum, which reduces the risk of cutaneous and fatty necrosis.
Sometimes, despite the importance of weight loss, fat deposits persist at the medial or external crural level. These are best treated by liposuction. Excess skin resulting from fat reduction is treated by excision. According to the axis of this surplus, we end up with a single scar in the inguino-crural fold extending if necessary in the inner side of the thigh.
In cases of major cutaneous and fatty excess, the resection is straightforward regardless of the length of the scar with excision in “orange quarters” centered on the bead, the aim being to avoid friction between the crural folds which prevent patients to walk.
In the event of a significant collapse of the abdominal skin, buttocks, and thighs, “circular abdominoplasties” are performed to correct both the curve of the lower limbs and the abdomen. This intervention is however long and requires a change of position of the patient during the procedure. The results can be spectacular.
In moderate excess skin, the incision is made with or without complementary liposuction.9 Liposuction is useful in cases of localized excess fat to prepare excision of the skin, as for the thighs. If excess cutaneous-fatty is major, it is necessary to make a scar on the inside of the arm with the excision of a part of the skin of the axillary hollow to redrape the cutaneous excess.
During significant weight loss, one can witness a melting of the breast volume parallel to a sagging of the breast envelope. Therefore, we use one of the different lifting techniques developed for breast ptosis surgery. In some cases, when the volume is insufficient, it is necessary to set up breast prostheses to give them a volume.
Although most patients desire an improvement of contour whatever the price to pay, the plastic surgeon must stress the importance of scars and their evolution over time. The problem must be understood before the operation, especially in the arms and legs because the scars are difficult to camouflage in these areas. Some patients renounce a gesture at this level, preferring to keep the excess cutaneo-greasy rather than scar too visible. For breasts and belly, the question arises less because scarring sequelae are hidden under the clothes.
The most common complications described in the literature relate to abdominoplasty, 11 withhematoma, wound dehiscence or local infections that occur in 5 to 10% of cases. Venous embolism or thrombosis occurs in 1% of cases. Studies do not differentiate plastic surgery interventions in patients who have benefited from bypass. On our small number of operated after bypass, we note only two superficial dehiscences of wounds requiring only local care. No embolism or venous thrombosis has occurred yet.
After-by-pass surgery allows still young patients to recover an acceptable figure at the cost of one or more surgical procedures and scars more or less important. These interventions are carried out as part of a multidisciplinary approach with different stakeholders also involved in the treatment: internist doctors, dieticians, psychologists, digestive surgeons, and plastic surgeons.
The surgical “remodeling” after massive weight loss can result in a significant improvement of the body diagram (self image, self-esteem), thus contributing to better socio-occupational integration and a significant reduction of health problems.