A critical review of the impact of reconstructive
surgery following massive weight loss on patient
QoL & a pilot study plan.
Jo Gilmartin, Mark Soldin & Prof
Andrew Long
Global Obesity Epidemic

A major health problem& a growing
number of morbidly obese patients are
seeking surgical solutions-bariatric surgery
 Experience ‘prejudice’ & ‘social exclusion’
 MWL often leads to excess of lax,
overstretched skin causing physical
dysfunction/ Psychosocial –QoL problems
Risk of Co-morbidities

For example, health consequences such as:
 Stress on joints, Fatigue, Insomnia
 Diabetes, Hypertension
 High blood cholesterol
 Strokes, DVT’s
 Heart attacks & kidney failure
 Anxiety & depression, Powerlessness
Fat Politics

Media ideal of thinness, denigrates fatness
by linking it to negative characteristics such
as ugliness, laziness, failure & anti-social.
 Marginalised by society
 Prominence of surveillance-power
inequalities
 Government public health campaignslifestyle choices (Tischner & Malson 2008)
Background

Patients seeking body contouring after
MWL constitutes a rapidly growing patient
population in plastic surgery practice (Song
et al 2006).

However, QOL outcomes following body
contouring appears to remain largely
unexplored territory.
Literature Review

Yielded 12 papers that met the inclusion
criteria
 7 studies reported that reconstructive
surgery following MWL correlated with
QoL in several areas (Migliori et al 2006,
Song et al. 2006, Pecori et al. 2007, Cintra
et al. 2008, Mitchell et al. 2008, Lazer et al.
2009 and van der Beek et al. 2010)
Results

7 of the studies utilised a retrospective approach.
For example,
 Au et al .(2008) undertook a retrospective random
chart review on patients who underwent body
contouring from 1993-2002.
 Other studies used a more scientific approach Van
der Beek et al. (2010) used OPSQ & Mitchell et
al (2008) employed an appearance questionnaire.
 A few studies used a prospective approach
3 Themes emerged
1.
Improved QoL

improved physical functioning,
improved mental well-being,
improved self-efficacy towards eating, improved
social acceptance, fewer problems of intimacy and
sexuality (van der Beek et al. (2010).
Lower scores in body uneasiness (Pecori et al. (2007)
positive thinking,
body image satisfaction, sexual life resumption or
improvement (Migliori et al. (2006)





Improved QoL (Cont’d)

Cintra et al. (2008) reported that 87.5% had
a positive self-esteem & a very good self
image,
 68.5 % declared freedom from dependence
or disability & a better sex life.
 Lazar et al. ( 2009) found that 84.6% had
improved QoL- better sexual relations
(74%), aesthetics (79.5%), psychological
status (86.5%) & current life (100%).
Improved QoL (Cont’d)

Song et al. (2006) found that body
contouring improved QoL significantly,
with a mean 55% overall improvement in
QoL measurements (n=13), p.<0.01).

Mitchell et al. (2008) found some
congruency between perceptions of
attractiveness & improved QoL.
2. Dissatisfaction from Body
Contouring

For example,

Occurrence of dogs ears in the scar.
Results did not match expectations based on Internet
examples (van der Beek et al (2010)
Dissatisfaction with skin breakdown, most commonly
reported being sores,
Rashes and skin breakdown in the waist/abdomen area
(25%), Chest/Breasts (19%),
Thighs (16%),
Rear/buttocks area (7%) (Mitchell et al. (2008)





Body Contouring
Body Contouring
3. Complications








The majority appeared to be related to:Wound dehiscence – ‘wound distruption’
Tissue necrosis
Wound infection
Serious Fluid collection
Seroma
Hematoma/DVT/PE
Anemia because of blood loss (Mustoe 2005; Au
et al 2008; Cintra et al. 2008 & de Kerviler et al.
2009)
Implications for health
professionals
Development of NSF & an ‘ideal’ care pathway
to empower this client group.
2. Educate patients about deciphering appropriate
sources of information to make a properly
informed decision about going ahead.
3. Regulation of cosmetic surgery is concerned with
enhancing standards of clinical excellence but
excluding ‘professional awareness of cultural &
social pressures on women patients’ ( Latham
2008, p.438).
1.
Implications for health
professionals cont’d
1.
2.
3.
4.
Emphasise patient choice, & promote a stronger patient
voice to create autonomy enhancing conditions.
The medical power relations appear to be asymmetricalscientific knowledge & medicalization.
Transactional notions of power exploited-problematic
Empower potential consumers to access counselling or
support networks.
Mapping- Hierarchy of
Evidence
Review Limitations
1.
2.
3.
4.
5.
Lack of Systematic Reviews & RCT’S.
Small Sample size.
Single centre database used in all of the studies.
Methodology is poorly articulated in some
studies (e.g. Mustoe 2005).
Many of the studies did not appear to
incorporate validated instruments.
Review Limitations

Some studies were preoccupied with
describing surgical procedures
 Others only used a case note review
 Some studies only included women in the
sample
 The majority used a retrospective approach
 There is a huge scarcity of high-level
evidence in regard to QoL Outcomes
Pilot Study

Aim:
1.
To identify tools & procedures to inform a large
scale multicentre study.
To identify QoL outcomes from body
contouring following massive weight loss.
Intent
To gain preliminary data for national
competitive grant applications to be submitted in
the 2011/2012 rounds.
2.
3.

Pilot Study- Approach

Mixed Methods
1.
Questionnaire- Obesity Psychosocial State
Questionnaire
2.
3.
Scales
Physical health, mental well-being, external
contentment, self-esteem, social judgements,
self-efficacy towards eating habits, intimacy &
sexuality, social network
Method’s Cont’d
2




3.
4.
5.
Semi- structured interviews to explore the
participant's experience before and after surgery,
focusing on general well-being,
body image/identity
emotional well-being,
levels of function and activity.
Demographics & weight characteristics - Medical
Records
Sample: 20 –25 patients
Study Site: Plastic Surgery Dept, St George’s
Hospital, London
Pilot Study – Phase 1

Preparation & submission of Pump Priming
BID –Successful Outcome.
 Preparation & submission of Ethical
application for approval –was gained from
South West London REC 4.
 Preparation & submission of R&D
application for approval –was gained from
St George’s Hospital, London.-Dec 2010
Pilot Study- Phase 2

1.
2.
3.
4.
5.
We are setting out to:
Identify & recruit 20-25 patients for the
pilot work- Invitation letters sent out
Undertake the field work- data collection
Undertake a rigorous data analysis
Disseminate the results
Prepare a grant application for a large
scale study
Large Scale Study

We are setting out to:

Develop a large scale Multicentred study in the
UK.
Establish a user group to inform the research &
ensure it addresses issues of importance to users.
Design a rigorous methodology.
Establish a dynamic research team.
Prepare a robust grant application.




References

Cintra W, Modolin, MLA, Gemperli R, Gobbi CIC, Faintuch J, Ferreira MC
(2008) Quality of Life after abdominoplasty in women after bariatric surgery.
Obesity Surgery. 18:728-732.
 Lazar CC, Clerc I, Deneuve S, Auquit-Auckbur I, Milliez PY (2009)
Abdominoplasty after major weight loss: improvement of quality of life and
psychological status. Obesity Surgery 19:1170-1175.
 Migliori F, Rosati C, D’Alessandro G, Giacomo G, & Cervetti S 2006. Body
Contouring after Bilopancreatic Diversion. Obesity Surgery, 16, 1638-1644.
 Mitchell JE, Crosby RD, Ertlet TW, Marino JM, Sarwer DB, Thompson
JK,Lancaster KL, Simonich H, Howell LM (2008) The desire for body
contouring surgery after bariatric surgery. Obesity Surgery 18:1308-1312.
 Mustoe TA (2006) Abdominoplasty:a comparison of outpatient and inpatient
procedures shows that it is a safe and effective procedure for outpatients in an
office-based surgery clinic. Journal of Plastic and Reconstructive Surgery.
523-524.
 Tisschner I & Malson H. (2008) Exploring the politices of women’s
in/visible ‘Large’ , Bodies. Feminism & P sychology , 17 (4). 260-267.
References




Pecori L, GiacomoG, Cervetti S, Marinari G M, Migliori F, Adami G F (2007)
Attitudes of morbidly obese patients to weight loss and body image following
bariatric surgery and body contouring. Obesity Surgery 17, 68-73.
Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH (2006)
Body
image and quality of life in post massive weight loss body contouring
patients. Obesity (Silver Spring) 14:1626-1636.
Van de Beek ESJ, te Riele W, Specken TF, Boerma D, van Ramshorst B
(2010) The impact of reconstructive procedures following bariatric surgery on
patient well-being and quality of life. Obesity Surgery 20: 36-41.