The Case for Body Contouring After Bariatric Surgery

By Thomas Crocker
Thursday, November 1, 2018

Body contouring has proven benefits for patients who have undergone bariatric surgery, but few avail themselves of it.

Bariatric surgery can result in massive weight loss and improvement or resolution of comorbid conditions, but it can also leave patients with excess skin that sags due to loss of elasticity. In a 2013 Saudi Arabian study of 64 bariatric surgery patients, nearly 90 percent experienced sagging skin after the operation.

“[F]or some patients, rapid weight loss leads to excess skin and soft-tissue deformities,” says Maria S. Altieri, MD, MS, Minimally Invasive and Bariatric Surgery Fellow at Washington University School of Medicine in St. Louis. “If extreme, this can lead to ... medical, psychological and cosmetic problems. Patients losing a large amount of weight would like to have a positive image of themselves, which is impaired by the excess skin causing body image dissatisfaction and low self-esteem.”

Folds of loose skin can also cause rashes, ulcers and infections, according to Dr. Altieri.

An Underutilized Benefit

Body contouring, which includes procedures to reshape the abdomen, arms, thighs, face, neck and other areas of the body, can reduce the incidence of skin conditions, according to Dr. Altieri. Plastic surgery may also defend against weight regain. A 2013 study by Swiss researchers found that, on average, individuals who underwent body contouring after bariatric surgery gained about 1 pound per year, compared with a 4-pound-per-year gain for those who did not have plastic surgery.

Yet few patients undergo body contouring. In a 2017 study by Dr. Altieri and colleagues at Stony Brook University in New York, less than 6 percent of 37,806 patients who had bariatric surgery in New York state from 2004 to 2010 later underwent body contouring. Insurance carriers often deem body contouring cosmetic and do not cover it.

“I think [body contouring] is underutilized, primarily because of cost issues,” says Newport Beach, California, plastic surgeon Edward Domanskis, MD, FACS, founder and President of the American Society of Bariatric Plastic Surgeons. “In most cases, these are complicated procedures. ... [S]ometimes, they involve several surgeries rather than just one.”

However, more patients are recognizing the benefits of body contouring and arguing for coverage by insurance carriers, Dr. Domanskis says. In the future, he envisions a single-fee option to cover both bariatric surgery and subsequent plastic surgery.

Criteria for Candidacy

Body contouring is best performed several months after bariatric surgery to give patients’ weight loss time to level off, according to Jeffrey Janis, MD, FACS, Professor of Plastic Surgery, Neurosurgery, Neurology and Surgery, and Chief of Plastic Surgery at University Hospitals, Ohio State University Wexner Medical Center, and President of the American Society of Plastic Surgeons.

“If someone is on the road to losing a significant amount of weight, to intercept that trajectory by doing some sort of body-contouring surgery while they’re still losing ... would be inappropriate,” Dr. Janis says. “You really want to see ... no less than three months of plus/minus 5 or 10 pounds from the goal weight [before contouring].”

Other key criteria, according to experts, include patients’ overall health, nutrition and tobacco use, as well as their expectations of surgery, as body contouring often involves multiple procedures and results in scarring.