Body Contouring after Biliopancreatic Diversion
Transcription
Body Contouring after Biliopancreatic Diversion
December 11/23/06 1:23 PM Page 1638 Obesity Surgery, 16, 1638-1644 Overview Body Contouring after Biliopancreatic Diversion Franco Migliori, Cristina Rosati, Gabriele D’Alessandro, Gian Giacomo Serra Cervetti Plastic Surgery and Burn Unit, San Martino University Hospital, Genova, Italy (Director: Franco Migliori, MD) Background: From Nov 2001 to Mar 2006, 176 patients underwent body contouring plastic surgery after prior biliopancreatic diversion (BPD). Weight loss had varied from 30-100 kg. The plastic surgery targeted the arms (24 patients), breast (58), abdomen (62) and thighs (20), plus torsoplasty (12). Methods: BPD is a “non-cosmetic” bariatric operation which results in malabsorption and subsequent major weight loss within 12 to 18 months. The typical “empty” aspect of the slimmed areas directed our surgical choices to specific techniques: brachioplasty, reduction mammaplasty and/or mastopexy (with or without prosthesis or “self-prosthesis” technique), thigh-lift, abdominoplasty and torsoplasty. We do not consider any liposuction technique suitable for this kind of patient, because of the specific histological changes caused by BPD. Results: The metabolic discrepancies following BPD affect postoperative management of these patients. A higher incidence of complications has been reported, of both systemic and local nature; the local ones, common in the abdominal wall, convinced us to perform an arteriographic study preoperatively, to check anatomical alterations following the BPD. Conclusions: Although the characteristics of BPD patients limit the choices, we are satisfied with the results of cosmetic correction and quality of life. All the patients, without exception, noted a high rate of positive thinking and have undergone further bodycontouring surgery (or plan to do so). Key words: Plastic surgery, morbid obesity, weight loss, bariatric surgery, biliopancreatic diversion Presented at the Second Congress of the IFSO-European Chapter, Lyon, France, April 28, 2006. Reprint requests to: Franco Migliori, MD, Direttore U.O. di Chirurgia Plastica e Centro Grandi Ustionati, 16132, Genova, Italy. E-mail: [email protected] 1638 Obesity Surgery, 16, 2006 Introduction This paper is intended to serve as an overview to this particular branch of body contouring after a specific bariatric surgical technique. Since 1976, Scopinaro’s biliopancreatic diversion (BPD) has evolved as a bariatric operation.1,2 BPD has made a malabsorptive approach acceptable and preferable. Normalization of serum glucose and cholesterol, a totally free diet, mortality <0.5%, and the extreme flexibility of the technique, are advantages. Clinical Consequences Significant advantages of BPD are: 1) the extreme weight loss (80-100 kg) within an average time interval of 12-18 months; 2) normalization of hyperglycemia and hypercholesterolemia. However, some challenging complications must be avoided: 1) Fe++ malabsorption with sideropenic anemia; 2) Ca++ malabsorption with bone demineralization; 3) in 5% of patients, protein malnutrition. Morphological Consequences The clearly evidenced disadvantage of the operation was the inefficacy of the soft tissue scar retraction due to histological alterations, causing an overall non-esthetic aspect. The inelastic and atrophic tissues result in deep folds and creases. The main aspects are large dermo-adiposal folds in the arms, abdomen and inner thighs, and medium-to-severe breast ptosis in women. © FD-Communications Inc. December 11/23/06 1:23 PM Page 1639 Body Contouring after BPD – Overview Anatomo-Surgical Consequences The preoperative and intraoperative challenge of plastic surgery after BPD has been the reduced vascular perfusion of the tissue, mainly in the dermis which appears thinner, and in the fat which appears hypotrophic, “pale” or even “gray”. The presence of medial scars in the abdominal wall causes reduced elasticity and a compromised dermal plexus, both causing increased specific complications. Histological Consequences A histologic study on the dermis and fat has been performed, compared with dermis and fat of healthy subjects. The post BPD fat has demonstrated the presence of collapsed adipocytes with thicker membranes, prominent nuclei (usually not visible) and thickened intracellular fibrous septa. In the dermis, the main evidenced alterations have been the thickening of the fibrous net and the hypertrophy of the vascular net. A reduction of elastic fibers is supposed, but results of histochemical EM study are awaited. Materials and Methods From Nov. 2001 to Mar. 2006, 176 patients (166 female, 10 male) have been operated: 24 branchioplasties, 58 mastoplasties, 62 abdominoplasties, 20 thigh-lifts and 12 torsoplasties. Due to the high risk of complications in these patients, we predeposit autologous blood in all cases (one or two units). In more complicated procedures (like torsoplasty), we verify the availability of a postoperative intensive care bed (for 1-2 nights). We perform antithrombotic prophylaxis with LMW heparin 4,000 IU 12 hours before surgery (continued every 12 hours for 2 weeks) and compressive leg bandaging. Hemoglobin level is checked immediately after surgery, 6 hours after surgery and every day for 2 weeks, to verify the need for auto-hemotransfusion. We have slightly prolonged the maintenance of the drains (4-5 days); we remove the drains only when 24-hour drainage is <100 cc. The recovery is not less than 6-7 days and up to 15-20 days for more complex techniques (torsoplasty). General Consideration in Choice of Surgical Technique As usually happens in plastic surgery procedures, the surgeon needs to find the right compromise between maximal reduction of excess tissue which could achieve a non-esthetic result, with the need, on the other hand, for more reduction of scar length.3 The anatomical-surgical and histological features confer to these tissues an “anergic behavior”, meaning a poor or absent scar retraction. Because these tissues have no retraction ability, the surgical techniques have to remove all excessive tissue. Thus, techniques such as liposuction, where the results depend on scar retraction, cannot be utilized except in rare selected cases. Surgical Techniques Brachioplasty The esthetic defects of the upper limbs have been classified into 4 types by Strauch.4 The defects following BPD mainly belong to the 4th type, and in some cases to the 3rd. The interested areas are mainly II and III (axilla).4 After an extensive international review,5 we are strongly convinced that the linear excision (with possible T extension in the axilla), performed within the medial brachial fold, gives the best esthetic result (Figure 1). Thigh-Lift While pursuing the aim of shortening the scars, we have gradually utilized more and more excisions following the suggestions of Le Louarn and Pascal.6 To reduce possible lymphatic drainage complications, we have gradually reduced the undermining extension, choosing a full-thickness “en block” removal of excessive tissue. The preoperative drawing of the planned procedure is performed with patients standing and the legs abducted. The removal of excess tissue is performed in the “gynecologic position”; the suturing is performed with the legs alternatively abducted, by anchoring together the dermis and superficial Colles fascial system (according to Lockwood7) (Figure 2). Mastoplasty The main breast problem after BPD weight loss is ptosis, which is seldom of high degree (Nipple Areola Complex [NAC] distance 28-35 – normal values 18Obesity Surgery, 16, 2006 1639 December 11/23/06 1:23 PM Page 1640 Migliori et al A B Figure 1. A: Before brachioplasty. A B Figure 2. A: Before thigh-lift. 20) and glandular hypotrophy. These two defects are frequently present together. Very rarely have we needed to reduce the gland volume. In minor ptosis (NAC lift of about 4-5 cm), we utilize round block technique, added, if necessary, with an alloplastic implant (Figure 3-1) or the self-prosthesis technique of Ribeiro8 (Figure 3-2). In a major ptosis, we utilize the vertical technique or L technique,9 eventually supplemented by a prosthesis or self-prosthesis. 1640 B: After brachioplasty. Obesity Surgery, 16, 2006 B: After thigh-lift. Abdominoplasty As a consequence of the above-described anatomosurgical modifications and of the high percentage of potential complications, we are convinced that the right abdominoplasty technique for this kind of patient should be quick and safe10 (Figure 4). Therefore, we usually utilize the “vest over pants” technique (Planas, 1978) with an inverted V excision, providing higher vascular safety.11 December 11/23/06 1:23 PM Page 1641 Body Contouring after BPD – Overview A B Figure 3-1. A: Mastoplasty case 1 before. B: Mastoplasty case 1 after (mastopexy with silicone implants). A B Figure 3-2. A: Mastoplasty case 2 before. B: Mastoplasty case 2 after (mastopexy with self-prosthesis). A Figure 4. A: Before abdominoplasty. B B: After abdominoplasty. Obesity Surgery, 16, 2006 1641 December 11/23/06 1:23 PM Page 1642 Migliori et al A B Figure 5. Torsoplasty. A: front. A B Figure 6. Torsoplasty results. A: Back before. C B: Back after. D C: Side before. 1642 B: back (with island flaps for buttocks emphasized). Obesity Surgery, 16, 2006 D: Side after. December 11/23/06 1:23 PM Page 1643 Body Contouring after BPD – Overview The high incidence of abdominal wall complications12,13 in this particular group of patients compared with “non-BPD” patients and the review of anatomical studies,14,15 has suggested to us to increase the research of causes by arteriographic study of the epigastric vessels. In five studied cases, no reliable modifications have been found. Therefore, without a demonstrated dysmetabolic pathogenesis secondary to BPD, the only certain cause responsible for almost 70% of trophic complications following abdominoplasty is the presence of previous scars. In more recent BPD cases operated by the laparoscopic approach (with very short abdominal scars), the percentage of complications has significantly decreased.16 Torsoplasty In patients with more massive weight loss (70-100 kg), it is possible to observe a particular trunk nonesthetism, the so-called “sharpei profile” (Sharpei is an Asian dog characterized by redundant inelastic skin). In this kind of “tridimensional” defect, a “bidimensional” technique like abdominoplasty is not adequate.17,18 In these cases, the correction of flanks and back profile is necessary, as well as of the ptosis of the buttocks and the external thighs. In these patients, we perform torsoplasty as described by Lockwood19 and Pascal-LeLouarn,20 supplemented by a de-epithelilized island flap, in order to emphasize the profile (Figure 5). We commence with the excision of the redundant tissue first on the back side, then on the lateral aspect and finally on the abdominal wall. The excisions are conducted in serial little segments, in order to reduce incarcerated blood losses as much as possible. The variety and complexity of correction obtained by torsoplasty, in a single surgical time (posterior and lateral lift, abdominal wall flattening, great removal of excess tissue, hernia repair) gives an improvement of the entire “silhouette”, which is not achievable with any other technique (Figure 6). Conclusions Great “positive” thinking of these patients towards body contouring creates enormous expectations for improvement in quality of life (similar to the expectations which motivated these patients toward bariatric surgery).21 Of these operated patients, 99% declare themselves completely satisfied with the obtained results and go on to further body contouring. These kinds of results are not achievable by bariatric surgery alone and/or by eating behavior normalization.22 On average, we perform 2-3 operations on each patient. The main points of patient satisfaction are: ”body image” greatly improved, self-esteem recovery, improvement in life relationships, and sexual life resumption or improvement. A body uneasiness test study is in progress in 5 different groups of these patients. References 1. Scopinaro N, Gianetta E, Pandolfo N et al. Biliopancreatic bypass. Proposal and preliminary experimental study of a new type of operation for the functional surgical treatment of obesity. Minerva Chir 1976; 31: 560-6. 2. Scopinaro N, Adami GF, Marinari GM et al. Biliopancreatic diversion. World J Surg 1998; 22: 936-46. 3. Baroudi R. Body sculpturing. Clin Plast Surg 1984; 111: 419-43. 4. Strauch B, Greenspun D, Levine J et al. A technique of brachioplasty. Plast Reconstr Surg 2004; 113: 1044-8; discussion 1049. 5. Guerrero-Santos J. Brachioplasty. Aesthetic Plast Surg 1979; 3: 1-4. 6. Le Louarn C, Pascal JF. The concentric medial thighlift. Aesthetic Plast Surg 2004; 28: 20-3. 7. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg 1988; 82: 299-304. 8. Ribeiro L, Canzl W, Buss A et al. Tuberous breast: a new approach. 1998; 101: 42-50. 9. De Longis E. Mastoplastica riduttiva. Mastopessi. La dermopessi. Colosseum Edition, 1997. 10.Matarasso A. Abdominoplasty. In: Achauer BM, Eriksson E, Guyuron B et al, eds. Plastic Surgery: Indications Operations, and Outcomes, Vol V. St. Louis: Mosby 2000: 2783. 11.Planas J. The “vest over pants” abdominoplasty. Plast Reconstr Surg 1978; 61: 694-700. 12.Nurkim MV et al. Incidence of hematoma and seroma in abdominoplasty with and without the use of drains. Rev Soc Bras Cir Plast 2002; 17: 69-74 (abstract). Obesity Surgery, 16, 2006 1643 December 11/23/06 1:23 PM Page 1644 Migliori et al 13.van Uchelen JH, Werker PMN, Kon M. Complications of abdominoplasty in 86 patients. Plast Reconcstr Surg 2001; 107: 1869-73. 14.Huger WE Jr. The anatomic rationale for abdominal lipectomy. 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Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty patients. Plast Reconstr Surg 2003; 112: 619-25. 22.Adami G, Bauer B, Gandolfo P et al. Body image in early-onset obese patients. Eat Weight Disord 1997; 2: 87-93. (Received June 22, 2006; accepted August 3, 2006)