Obesity is unquestionably an important pathology with a very high social impact and represents one of the greatest public health challenges of the last decades. Statistical information on this disease shows that we are facing one of the largest ‘‘epidemics’’ of our century. According to data, in the USA, more than 2 in 3 adults (70.2%) were considered to be overweight or have obesity  and in European Union countries, overweight affects 30–70%, while obesity affects 10–30% of adults  

Nowadays, bariatric surgery is the most effective long- term treatment for massive obese patients, as it improves or even resolves obesity-related comorbidities . 

In our experience, postbariatric patients are usually very motivated and they are enthusiastic users of the Web as a source of information on the different type of surgery they could undergo after their weight loss in order to reshape and remodel their body thus regaining physical and functional wellness and dignity .

Excess skin resulting after massive weight loss is considered stigmatizing, and it leads to a decline in quality of life and can increase risk of weight regain . The main part of postbariatric patients defines loose skin as a negative consequence of surgery . In those patients who feel uncomfortable and unattractive after bariatric surgery, body recontouring plastic surgery allows self-perceived physical appearance to return to values comparable to those of the normal population and significantly increases their quality of life .

Bariatric surgery is currently considered to be the most effective therapy for weight loss and obesity-related comorbidities in patients with severe obesity; however, the definition of success is still under debate but it is clear that by using any proposed criteria, we will always find at least a few patients that will struggle to get to the goal weight and most of them will regain some of the weight after a few years.Bariatric surgery doesnt affect your body fatt cells count.Fat cells still is in your body and every living cells needs energia.If fat cells is not removed, you should struggle with eating

All bariatric operations are going to fail to some extent over time , except for those who have had excess skin removal surgery.

Abdominoplasty
Lower trunk lifting or belt lipectomy
Vertical abdominal dermolipectomy ,reduction mammoplasty
Vertical mastopexy with augmentation
Vertical mastopexy (Lassus, Lejour) Gynecomastia
Upper trunk lifting
Gluteal fat injection
Thigh lifting
Arm lifting
Face-neck lifting

ABDOMINOPLASTY AND LOWER BODY LIFT (BELT LIPECTOMY)

The most common post-bariatric surgical procedure is abdominoplasty, but patients who have lost 35 – 45 kg or more will require more extensive surgery. In such cases, we recommend a lower body lift or belt lipectomy, in which the lower body is treated front and back in its entirety. The flanks, sides and backs of the thighs, and the buttocks are treated at the same time as the stomach. A sagging mons veneris (mons pubis) can be reduced and lifted. In some cases, a vertical incision can be made in the centre of the abdomen, or a standard bikini line incision combined with a vertical incision, so that the scar resembles an inverted «T».

Omitting any of these interventions may produce a poor functional and cosmetic outcome . A circumferential lower body lift takes 3 – 5 hours and requires 1 – 4 days of hospitalisation. The recovery period is normally 4 – 6 weeks providing there are no complications

Excess skin after bariatric surgery

Skin that has been stretched over long periods shows reduced elasticity , and massive weight loss is often accompanied by a corresponding amount of excess skin. Many patients who undergo bariatric surgery develop such severe physical impairments that they require corrective plastic surgery Indeed, most patients (70 – 90 %) express a wish for plastic surgery after weight-loss surgery Indications and contraindications

Excess skin can cause various complaints, including intertriginous ulcerations and infections of the skin folds and navel, unpleasant odours, back and neck problems, aches and pains associated with work, exercise and intimacy, skin lesions due to chafing, difficulty finding clothes that fit and disparity between appearance and age The abdominal area causes the most problems, followed by the chest and the thighs . Excess skin can therefore become a new source of stigma, social isolation and reduced quality of life for these patients

The risk of complications associated with body contouring surgery after pronounced post-bariatric weight loss varies depending on factors such as the size and scope of the procedure, nutritional status, smoking and the degree of overweight. Medical comorbidities are not a contraindication for plastic surgery, but limit the choice of procedures due to a greater risk of complications and suboptimal results

Prior to plastic surgery, the patient must have good nutritional status, haemoglobin levels > 10 g/100 ml and have a satisfactory level of physical fitness . Any gastrointestinal pain after weight-loss surgery should be investigated and treated prior to evaluation for plastic surgery, as it may otherwise be difficult to distinguish sequelae of abdominoplasty from pain in the digestive system. Patients with previous deep vein thrombosis or lymphoedema should be advised about the risk of relapse, and adequate thromboprophylaxis must be ensured

Plastic surgeons often set the upper BMI limit for body contouring surgery at 30 kg/m² due to fear of complications and because removal of skin is easier if there is not much additional fat .

Body contouring surgery or local removal of skin?

In our experience, body contouring surgery is most likely to produce a successful cosmetic outcome and few adverse effects in a «healthy» non-smoking patient with BMI < 28 kg/m². Such patients have a normal body fat distribution, but they have excess skin that hangs in folds, which can be a challenge when contouring .

In such cases, treatment usually begins with surgery on the lower body – abdominoplasty, outer thighs, flanks and buttocks. The next session focuses on the upper body – chest, arms and upper back. Lastly, the thighs are treated in a separate operation in which minor corrections can also be made to previous procedures. We recommend up to three months between operations so that patients can recover before the next intervention.

As with any surgery, there is a learning curve – with increased experience the operating time is reduced, there are fewer complications and more procedures can be performed in a single session.

In our experience, local removal of excess skin does not meet patients’ expectations and treatment of one area can quickly lead to further treatment of adjacent areas. Body contouring surgery after significant weight loss involves a series of procedures to reduce or remove excess skin on the abdomen and hips, chest and upper arms as well as the buttocks and thighs. The interventions are based on fundamental plastic surgery techniques, but have a distinctive character due to the extent of the resections, which increases both surgery duration and risk.

Time-consuming major surgery in the form of whole-body reshaping increases the risk of blood loss, hypothermia, infection, fat necrosis and wound complication. This has resulted in an increasing tendency to split up procedures; several interventions within a single body area might be combined, while surgery on other areas is left to a later date . Treatment is tailored to each patient according to his or her needs, health status and expectations.

ABDOMINOPLASTY AND LOWER BODY LIFT (BELT LIPECTOMY)

The most common post-bariatric surgical procedure is abdominoplasty, but patients who have lost 35 – 45 kg or more will require more extensive surgery. In such cases, we recommend a lower body lift or belt lipectomy, in which the lower body is treated front and back in its entirety. The flanks, sides and backs of the thighs, and the buttocks are treated at the same time as the stomach. A sagging mons veneris (mons pubis) can be reduced and lifted. In some cases, a vertical incision can be made in the centre of the abdomen, or a standard bikini line incision combined with a vertical incision, so that the scar resembles an inverted «T».

Omitting any of these interventions may produce a poor functional and cosmetic outcome . A circumferential lower body lift takes 3 – 5 hours and requires 1 – 4 days of hospitalisation. The recovery period is normally 4 – 6 weeks providing there are no complications .

PANNICULECTOMY – REMOVAL OF ABDOMINAL PANNUS (FAT APRON)

For patients who are not suitable for body contouring surgery due to significant obesity, panniculectomy can be considered on the basis of medical indication. These patients usually have a large and heavy fat apron, which impedes activity and can result in long-lasting fungal infections  or serious soft tissue infections such as cellulitis or necrotising fasciitis.

The risks of surgery have been described as very high for these patients, but there is little evidence available regarding outcomes and frequency of complications. We have performed panniculectomies with resections of 7 – 20 kg without major complications. However, our patient sample is too small for us to draw any firm conclusions about the frequency of complications in this group, who are among our most grateful patients despite suboptimal cosmetic outcomes .

UPPER BODY

The upper body is treated after surgery on the lower body. Loose skin on arms, axillae and chest, upper abdomen or back may be isolated to one area or affect the entire upper body.

Treatment consists of breast reduction or breast lift (mastopexy). In women, skin flaps from the surrounding area can be used for breast reconstruction (mammoplasty). The axillae can be treated at the same time as the arms or chest with axilloplasty. Greater emphasis is often placed on treatment of the chest and arms, which can result in the axilla receiving insufficient attention. Our experience suggests that best results are achieved when the arms, axillae and chest are treated in the same session.

THIGHS

Thighplasty is performed in patients with pronounced physical impairments due to excess medial skin, which can extend all the way down to the knees. Correcting this requires removal of skin and adipose tissue vertically in order to reduce circumferential excess skin. This entails a long and sometimes unsightly vertical scar from the groin to below the knee. The surgery takes 1.5 – 3 hours.