Body Contouring after Biliopancreatic Diversion

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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: franco.migliori@hsanmartino.it
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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.
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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
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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.
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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
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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.
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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.
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B: back (with island flaps for buttocks emphasized).
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D: Side after.
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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.
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(Received June 22, 2006; accepted August 3, 2006)