Monday, August 27, 2007

Plastic Surgery after Massive Weight Loss

This posting is in response to a request to comment on cosmetic surgery for excess skin in the abdomen and other places, after weight loss surgery.

Body contouring, body lift, body shaping or body reshaping are alternative terms used to describe a group of plastic surgery procedures performed after massive weight loss, to manage hanging excess skin. Patients have to have reached a stable plateau weight before any such plastic surgery procedures. The person should have lost at least 100 pounds or achieved the target or maximum weight loss, had a stable weight for a good length of time after the weight loss surgery, and be in good health and not planning on becoming pregnant. Good candidates for a body lift should also have no medical problems that prevent them from going under general anesthesia for major surgery, and should not smoke. Smoking decreases blood flow to the tissues and, therefore, may slow healing.

Plastic surgery procedures after weight loss surgery include the following:

1. Panniculectomy: This is excising the "pannus", which is the excess hanging skin that is present below the belly-button.

2. Abdominoplasty (Tummy Tuck): Includes dissection and preservation of the umbilicus itself, and a more extensive skin mobilization and more aggressive skin removal than panniculectomy. A complete abdominoplasty also includes tightening of the abdominal wall muscles. Abdominoplasty and incisional hernia repair can be combined into a single procedure.

3. Arm lift or brachioplasty.

4. Breast lift or mastopexy.

5. Lower body lift is a combination of an abdominoplasty, plus a thigh and buttock lift. It requires a large incision around the belt line to lift the lower body.

6. Liposuction uses small, narrow tubes to remove fat and is often used in combination with other lifting procedures to help achieve better contouring in various parts of the body.

Combining multiple "lifts" entails longer operative time, and more potential blood loss, but is very appealing to many patients, from the stand-point of time off work and out-of-pocket costs. Combined procedures are avoided if there is active smoking history or medical problems that make a longer operation a particularly risky undertaking.

Insurance coverage varies from carrier to carrier, and a carrier may have different plans with different provisions. Almost all insurance carriers specify that coverage of aesthetic (cosmetic) surgery is excluded. Definition of medical necessity, that is essential for coverage, is variable.

Possible complications after body-contouring surgery include seroma (collection of thin serous or serosnaguineous fluid), hematoma (collection of blood), wound separation (usually minor), swelling and scarring. All patients will have scars, and basically the surgery trades excess skin for scars. For a small number of patients, scars can be excessively thick or inflamed. Before going for body contouring surgery, any nutritional deficiencies (as protein malnutrition, anemia, loss of muscle mass, and osteopenia/osteoporsis) need to be addressed and corrected.

Body contouring is considered major surgery. The outcome of body shaping is generally extremely satisfying to patients. It may take several months to see the final results of the procedure.

Obesity Rates - still on the rise :(

I thought the obesity epidemic is plateauing. Well, News Flash! Obesity and overweight rates continue to rise. A new report by Trust for America's Health (TFAH) showed that in 31 states, obesity rates got worse in the past year. State of Washington is actually one of them. Moreover, all states fail to meet the national goal of reducing adult obesity levels to 15 percent by the year 2010. The adult obesity rate of the State of Washington is 22.4 percent, ranking it the 31st heaviest in the nation, according to TFAH's report titled "F as in Fat". Mississippi is top of the list. Colorado continues to be the leanest.

The report noticed that 16 states and Washington, D.C. have passed taxes on junk food or sodas, including Arkansas, California, D.C., Illinois, Indiana, Kentucky, Maine, Minnesota, Missouri, New Jersey, New York, North Dakota, Rhode Island, Tennessee, Texas, Virginia, Washington, and West Virginia.

The full report with complete state rankings in all categories is available on TFAH's Web site at The report was supported by a grant from the Robert Wood Johnson Foundation.

Sunday, August 26, 2007

Vitamin D supplements and Obesity

Did you know that there is a high incidence of vitamin D deficiency with obesity? The reason is probably that vitamin D is fat-soluble, so it deposits in the fat stores, and becomes less available to the body. There is a possibility that lack of adequate sun exposure, which is common in Seattle area and in the Northern regions, could contribute to a baseline vitamin D deficiency. This means that a typical patient most likely has a deficit of vitamin D before bariatric (weight loss) surgery. A study from the University of Maine, that was recently published in the journal "Surgery for Obesity and Related Diseases" (1) , showed the results of evaluating how adequate the correction of vitamin D deficiency is, one year after gastric bypass surgery. Before surgery, 34% of patients had suboptimal levels, and 54% had deficient levels, of 25-hydroxyvitamin D in their blood. By one year after Roux-en-Y gastric bypass surgery, the vitamin D deficiency improved remarkably with the intake of vitamin D supplements. Remember, nutritional supplements after weight loss surgery are not optional, they are a must. The researcher recommended higher doses of vitamin D than the average.

Vitamin D is essential for bone health. Calcium absorption requires vitamin D. Lack of calcium leads to osteopenia and osteoporosis. So, when you take your supplements, particularly after bariatric surgery, make sure that they include calcium and vitamin D. Actually, it may be better to start before having the surgery. Notice, though, that there are medical conditions in which taking extra calcium may be contraindicated. Therefore, make sure that your physician is OK with it. Also, after gastric bypass, the general recommendation is to take the calcium supplements in the form of calcium citrate, not carbonate. There is some controversy in that issue, but taking calcium citrate will keep you on the safer side, with regards to calcium absorption.

So, make sure that you take your nutritional supplements regularly, and stay healthy.


(1) Nelson ML, Bolduc LM, Toder ME, Clough DM, Sullivan SS. Correction of preoperative vitamin D deficiency after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2007 Jul-Aug;3(4):434-7. [PMID: 17400028]

Saturday, August 25, 2007

Can TV ads influence our kids' taste buds?

This is not exactly a bariatric surgery topic, but, nevertheless, a very interesting one. Does advertising/branding affect children's taste? Well, we know that TV ads do influence kids, who, as a consequence, keep begging and nagging for an advertised product. The pressuring will intensify, once other parents provided your kids friends with the product. What standing do you have when you stick to the hated "No", while the attractive TV ads say "yes", and peers' parents have given the sign of approval?

A very interesting study came from Stanford Prevention Research Center and Stanford University School of Medicine. It was published in the August, 2007, issue of the "Archives of Pediatrics & Adolescent Medicine." (1) Kids aged 3-5 years (yes, that young!) were entered into a food tasting game, where they were given 2 identical food items, one wrapped in a McDonald's typical wrapping, and the other wrapped in a plane white wrapping. Items included not only hamburgers, fries and chicken McNugget's, but also baby carrots, which are not even sold at McDonald's, but were placed on top of a McDonald's french fries bag and on top of a matched plain white bag. McDonald's was chosen because it is a good example of a well-branded and heavily marketed source. Guess what? There was a statistically significant higher taste preference for the foods associated with the branded wrappings. This study is remarkable for its hypothesis, and the results that came out of it.

The authors concluded that branding of foods and beverages influences young children's taste perceptions. The authors also suggested that branding may be a useful strategy for improving young children's eating behaviors.

No wonder, a report of a joint "WHO/FAO Expert Consultation" indicated that: "Heavy marketing of fast-food outlets and energy-dense, micronutrient-poor foods and beverages" is a "probable" cause of excess weight gain and obesity. There has been strong evidence of a relationships between television viewing and obesity in children. Could that be, at least partially, due to the food advertising to which they are exposed? You bet.

(1) Robinson TN, Borzekowski DL, Matheson DM, Kraemer HC. Effects of fast food branding on young children's taste preferences. Arch Pediatr Adolesc Med. 2007 Aug;161(8):792-7. PMID: 17679662

Wednesday, August 22, 2007

Bariatric Surgery Lowers Long-Term Mortality

More data to support that bariatric surgery may improve mortality. Two new studies are published in the August 23, 2007 issue of the New England Journal of Medicine, indicating that bariatric surgery resulted in decreased overall mortality, in addition to the known effective long-term weight loss. One study came from Utah (Adams et al.). The other came from Sweden (Sjöström, et al). In an Editorial in the Journal, Dr. George A. Bray of the Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, commented that those articles "may provide the missing link between intentional weight loss and lives saved for obese patients"

The Utah study is a retrospective study that aimed at determining the long-term mortality among more than 9000 patients who had undergone gastric bypass and a comparable number of severely obese persons who applied for driver's licenses. During follow-up averaging 7 years, mortality in the surgery group decreased by 56% for coronary artery disease, by 92% for diabetes, and by 60% for cancer. On the other hand, mortality from accidents and suicide, was 58% higher in the surgery group than in the control group. All in all, there was a survival benefit from bariatric surgery.

The other article titled "Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects" reports a prospective, controlled Swedish Obese Subjects study involving more than 4000 obese subjects. The study reports on the overall mortality during an average of 10.9 years of follow-up with an impressive follow-up rate of 99.9%. The study concluded that bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality.


Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, Lamonte MJ, Stroup AM, Hunt SC.Long-term mortality after gastric bypass surgery.N Engl J Med. 2007 Aug 23;357(8):753-61. PMID: 17715409 (Full Text)

Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Agren G, Carlsson LM; Swedish Obese Subjects Study.Effects of bariatric surgery on mortality in Swedish obese subjects.N Engl J Med. 2007 Aug 23;357(8):741-52. PMID: 17715408 (Full Text)

Saturday, August 18, 2007

Does fibromyalgia improve after weight loss surgery?

Well, there are not too many studies that specifically address this issue. Of course the medical literature is full of evidence that musculoskeletal painful conditions in weight-bearing joints do improve with weight loss surgery in the vast majority of patients. However, when it comes to non-weight-bearing joints, and to fibromyalgia in particular, such information is scarce.

However, a study from the University Hospitals of Cleveland that was published in January 2007 did, indeed address that issue. (1)

Fibromyalgia syndrome (FMS) is one of the most common musculoskeletal diseases. Patients have fatigue, chronic diffuse musculoskeletal pains, poor sleep, and stiffness. There is no blood test to diagnose fibromyalgia. To make a diagnosis of FMS, widespread pain symptoms must exist for at least 3 months. The diagnosis is confirmed by finding at least 11 of 18 specific areas of point tenderness. Almost 9:1 patients are females.

In the study from Cleveland, FMS decreased by an impressive 90% after bariatric surgery. As for upper extremity pain, that is, of course,non-weight-bearing, 79% of patients had pain before surgery, compared to 40% after bariatric surgery.


(1) Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW. Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond). 2007 Jan;31(1):114-20.

Monday, August 13, 2007

Pregnancy and Bariatric Surgery

A recent article from the University of Texas at Houston, TX (1), that appeared in the August issue of the Archives of Pediatric and Adolescent Medicine, reported that the mothers of offspring with some important birth defects (including spina bifida and heart defects) are more likely to be obese than mothers of offspring who do not have any of those defects. The authors admitted that the mechanisms are unknown, but a relationship to undiagnosed diabetes was proposed.

Is it good to have low birth weight? The answer is, generally, No. Studies of populations in the United States and Europe have indicated a significant increase in the incidence of certain diseases in adulthood (coronary artery disease, stroke, and type 2 diabetes) among the low birth weight. This is interesting because the same adult diseases have higher incidence with adulthood obesity. So, does low birth weight correlate with obesity later on? A study about a famine in the Netherlands in the 1940s (2) did show that at the age of 19, the offspring of mothers exposed to the famine during the first half of pregnancy did have higher incidence of obesity.

Previous reports concluded that fetal exposure to diabetes in the uterus is an independant risk for the development of diabetes later in life. Pregnancy in patients with morbid obesity may lead to higher incidence of gestational diabetes and hypertension, preeclampsia, large-for-age fetus, preterm labor, and antepartum stillbirth. (3,4)

So, is it good to be pregnant after bariatric surgery? A review article that appeared in May 2007 in the journal "Medical Clinics of North America" (5) concluded that pregnancy after weight loss surgery is safe and has good outcomes. Cesarean deliveries occur more frequently in all of the reports of pregnancies after bariatric surgery when compared with the general population. Interestingly, there is also a higher incidence of cesarean section deliveries with obesity (3)

In general, it is recommended that pregnancy be avoided during the period of maximal weight loss, typically the first 18-24 months after a gastric bypass. When pregnancy does occur, there is a risk of malnutrition and anemia if ntritional supplements are not taken as advised. With that precaution in mind, studies of pregnancy after gastric bypass (6) and Lap Band (7) showed normal and healthy outcomes. A study from Australia (6) reported that pregnancy outcomes after Laparoscpic Adjustable Gastric Band Placement (Lap Band) are consistent with general community outcomes rather than outcomes from severely obese women.

A word of warning. There have been reports of rare incidences of internal herniation causing dangerous bowel obstruction late in pregnancy after laparoscopic gastric bypass. Though rare, such a possibility should be kept in mind if a pregnant develops acute abdominal pain or signs of bowel obstruction late during pregnancy.(8-10)


(1) Waller DK, Shaw GM, Rasmussen SA, Hobbs CA, Canfield MA, Siega-Riz AM, Gallaway MS, Correa A; National Birth Defects Prevention Study. Prepregnancy obesity as a risk factor for structural birth defects. Arch Pediatr Adolesc Med. 2007 Aug;161(8):745-50. PMID: 17679655

(2) Ravelli GP, Stein ZA, Susser MW. Obesity in young men after famine exposure in utero and early infancy. N Engl J Med. 1976 Aug 12;295(7):349-53. PMID: 934222

(3) Hall LF, Neubert AG. Obesity and pregnancy. Obstet Gynecol Surv. 2005 Apr;60(4):253-60. PMID: 15795633

(4) Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol. 2004 Feb;103(2):219-24. PMID: 14754687

(5) Patel JA, Colella JJ, Esaka E, Patel NA, Thomas RL. Improvement in infertility and pregnancy outcomes after weight loss surgery. Med Clin North Am. 2007 May;91(3):515-28, xiii. PMID: 17509393

(6) Dao T, Kuhn J, Ehmer D, Fisher T, McCarty T. Pregnancy outcomes after gastric-bypass surgery. Am J Surg. 2006 Dec; 192(6):762-6. PMID: 17161090

(7) Dixon JB, Dixon ME, O'Brien PE. Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol. 2005 Nov;106(5 Pt 1):965-72. PMID: 16260513

(8) Ahmed AR, O'Malley W. Internal hernia with Roux loop obstruction during pregnancy after gastric bypass surgery. Obes Surg. 2006 Sep;16(9):1246-8. PMID: 16989713

(9) Baker MT, Kothari SN. Successful surgical treatment of a pregnancy-induced Petersen's hernia after laparoscopic gastric bypass. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):506-8. PMID: 169252793

(10) Charles A, Domingo S, Goldfadden A, Fader J, Lampmann R, Mazzeo R. Small bowel ischemia after Roux-en-Y gastric bypass complicated by pregnancy: a case report. Am Surg. 2005 Mar;71(3):231-4. PMID: 15869139