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- Research Methods and Procedures
Objective: Because post-bariatric surgery patients undergo massive weight loss, the resulting skin excess can lead to both functional problems and profound dissatisfaction with appearance. Correcting skin excess could improve all these corollaries, including body image. Presently, few data are available documenting body image and weight-related quality of life in this population.
Research Methods and Procedures: Eighteen patients who underwent both bariatric surgery and body contouring completed our study. Both established surveys and new surveys designed specifically for the study were used to assess body perception and ideals, quality of life, and mood. Patients were surveyed at the following time-points: pre-body contouring (after massive weight loss) and both 3 and 6 month post-body contouring. Statistical testing was performed using Student's t test and ANOVA.
Results: The mean age of the patients was 46 ± 10 years (standard deviation). Quality of life improved after obesity surgery and was significantly enhanced after body contouring. Three months after body contouring, subjects ascribed thinner silhouettes to both current appearance and ideal body image. Body image also improved with body contouring surgery. Mood remained stable over 6 months.
Discussion: Body contouring after surgical weight loss improved both quality-of-life measurements and body image. Initial body dissatisfaction did not correlate with mood. Body contouring improved body image but produced dissatisfaction with other parts of the body, suggesting that as patients become closer to their ideal, these ideals may shift. We further developed several new assessment methods that may prove useful in understanding these post-surgical weight loss patients.
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- Research Methods and Procedures
Patients seeking body contouring after massive weight loss constitute a rapidly growing patient population in plastic surgery practice. As increasing numbers of bariatric surgical patients achieve success, they are left with post-weight loss deformities of loose, ptotic skin envelopes and residual adiposities that compose contour irregularities (1, 2). In addition to causing intertriginous rash, hygiene struggles, and difficulties with mobility, these deformities have the potential to cause personal distress regarding appearance. In 2003, 52,000 post-bariatric weight loss patients underwent body contouring, and a 36% increase was estimated for 2004 (3).
As body contouring practice undergoes explosive expansion, there is a need for documentation of psychological, social, and functional features of body contouring. The tangible changes in appearance from these procedures have been documented by various surgeons (1, 2, 4, 5). However, quality of life and psychological function of post-bariatric weight loss patients remain largely unexplored territories. These topics necessitate inquiry, so that we may properly document relief of prior dysfunction with surgical treatment (6). At the current time, we have not verified that surgical correction of these post-weight loss deformities can positively impact either quality of life or psychosocial function.
A past study of non-bariatric esthetic patients showed promising results, indicating that at 6 months after surgery, the patients displayed improved psychosocial function and self-esteem (7). In esthetic surgery, quality of life and body image constitute the most contributive aspects of patient satisfaction (8). Body contouring after bariatric surgical weight loss resides at a perplexing intersection between esthetic and functional surgery. The philosophical debate is whether body contouring after weight loss is a vanity operation, the completion step of surgical treatment for severe obesity, or both. It has been documented that surgical weight loss alone has a beneficial influence on psychosocial functioning and body image (9). To the best of our knowledge, the possible added benefit of post-weight loss body contouring has not been well investigated.
Obesity, negative body image, and quality of life are inextricably linked (10). Compared with normal-weight individuals, obese persons overestimate or distort body size more, are more dissatisfied and preoccupied with physical appearance, and avoid more social situations because of their appearance concerns (11). Body image dissatisfaction (BID)1 has been described as the most consistent psychosocial consequence of obesity (12). Although post-bariatric surgical weight loss patients are frequently no longer obese, their skin and soft tissue deformity may impart the appearance of residual obesity.
Previous investigations have concluded that obese individuals who lose weight by either non-surgical or surgical methods self-report improved body image (13, 14). Despite this positive impact, body image is seldom studied in obesity treatment programs. It has been confirmed that the amount of weight loss is not correlated to degree of improvement in body image, suggesting that perception is more important than actual improvement (15). To our knowledge, there has been no documentation of improved body image ascribed to body contouring after massive weight loss.
The plastic surgery discipline has been surprisingly reticent in studying body image and quality of life (16, 17, 18). Body contouring after surgical weight loss, being a relatively new subspecialty within plastic surgery, particularly lacks both standardized methods of assessment and knowledge of expected clinical outcomes. We need to perform careful and sophisticated outcome studies that can offer proof of the value of our service to this particular population (19).
Although it may seem logical to believe that additional alteration in appearance should trigger changes in body image and quality of life in post-bariatric weight loss patients, this is largely speculation. In a patient who has undergone such a striking transformation in appearance from massive weight loss, the benefit imparted by contouring procedures may be minimal in comparison. On the other hand, it is also possible that patients with post-bariatric contour deformities cannot fully reap the psychological rewards of massive weight loss. BID in these patients may remain prevalent due to residual feelings of unattractiveness and self-consciousness.
Few previous investigations have explored the psychosocial aftermath of post-bariatric surgery weight loss body contouring. We aimed to study body perception and ideals, condition-specific and general quality of life, and mood stability in these patients. Body contouring could be an ancillary cosmetic procedure unrelated to the treatment of obesity or the concluding stage of obesity treatment. In our experience, we have encountered more patients who consider body contouring to signify the culmination of their weight loss management.
Bariatric patients undergoing massive weight loss and body contouring most likely will undergo considerable shifts in body image and quality of life. We investigated several parameters.
Body Perception and Ideals
We investigated whether body contouring surgery results in a quantifiable difference in self-perception of appearance and if surgery changes their body ideals. We also determined whether these patients have a stable view of their pre-weight loss appearance. In a past study, obese patients were biased toward a more favorable perception of their body silhouette compared with normal-weight controls (20).
Body Image Satisfaction and Areas of Distress
Surgical weight loss patients often have substantial deformity. In a previous study, cosmetic patients experienced improved body image that is specific to the area of correction, rather than overall body image (21). We assessed body image satisfaction before and after body contouring surgery and identified the most problematic body areas in this patient population. In our clinics, we have noted that patients who have had contouring procedures often desire additional surgeries. We attempted to assess the patterns of body image dissatisfaction as they emerged.
General and Condition-Specific Quality of Life and Associated Mood
Presently, there is little documentation of how body contouring surgery can impact quality of life or mood in these patients. We identified potential changes in global and condition-specific quality of life in the post-body contouring period.
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- Research Methods and Procedures
We have demonstrated that body contouring after surgical weight loss improves quality of life and body image. Recruitment proved challenging for our longitudinal study (i.e., we recruited 40 people and obtained complete data for 18 patients). Thus, it is of particular interest that despite a relatively small sample size, we found significant differences. There were no demographic differences between people who completed the study and those who chose not to.
Because the majority of these patients are no longer overweight and unfit, traditional HRQOL measurements may be insufficient to demonstrate these improvements. In our group, mood was unaltered by body contouring surgery. Body image satisfaction improved in areas that underwent a body contouring operation, and this change resulted in increased overall body satisfaction. Body contouring resulted in a discernible effect on the self-perception of the patient's current silhouette. Patients after body contouring displayed a trend toward choosing a leaner silhouette as their ideal silhouette, indicating a shift toward a thinness ideal possessed by the general society. Body contouring did not change self-perception of appearance before massive weight loss, indicating a stable view of their former appearance.
Our investigation verified that body image satisfaction improved with body contouring surgery and that these improvements were regional, if not specific, to the areas that underwent treatment. We further demonstrated that treating one area of distress has the potential to reveal additional areas of dissatisfaction. Contouring one area of the body may throw the other areas into relative disproportion, which may impel the patient to notice additional areas of possible enhancement. Additionally, removing large amounts of skin frequently revealed areas of deformity that were previously hidden from view; for example, after resection of a hanging pannus, the medial thighs became a frequently mentioned area of distress.
Common sense would dictate that mood symptoms would have a profound effect on self-esteem and that global pessimism would negatively impact body image and quality of life. The surgical weight loss patients in our study had a fairly prominent history of depression. However, we do not believe that depression had an impact on our results. All of our patients fell within the normal range on the Beck Inventory scale before body contouring, and only two patients fell into the mild depressive symptoms category after body contouring. Perhaps the mild dysphoria in these two patients resulted from a growing self-awareness that body contouring was not the panacea for their BID.
Patients seeking plastic surgery are, in general, psychologically healthy, especially for corrective operations. Their considerable appearance-related psychosocial problems are related to the body parts of concern, and their expectations are realistic (30). However, expectation and ideal are often mismatched. In a previous investigation by Sarwer et al. (31), women subjects chose one silhouette size smaller than the body size they considered attainable. The authors suggested that because of this phenomenon, obese women, even on achieving significant weight loss, would probably not be satisfied with the results. Body image dissatisfaction is both global and specific to areas of distress and is especially prominent in obese women (32). However, the majority of even normal-weight individuals are dissatisfied with their appearance, and this normative discontent makes BID in these post-massive weight loss patients not only unsurprising, but expected (31, 32).
As we establish appropriate quality-of-life and body image measurements in the post-bariatric surgery weight loss patients, we are identifying procedure of interests and comorbid conditions, choosing or designing instruments to measure treatment outcomes, and studying outcomes prospectively. The growing emphasis on cost-effectiveness in the health care industry has highlighted the need for comprehensive outcomes research (33). To accurately demonstrate improved quality of life and functional status in our patients, plastic surgeons should perform outcomes-based studies (34).
In plastic surgery, outcomes are often vague and notoriously challenging to measure. Because psychosocial functional results are subjective and difficult to quantify, we may need instruments that are specific to both the patient population and the procedure or intervention (19, 35). Racial and sexual differences should be considered, but these differences may not be salient enough to warrant separate instruments (36, 37).
Many existing instruments were explored and piloted to more than 30 post-bariatric weight loss patients in a support group setting before the launch of our study. Several concerns arose with these established methods. The main problem with MBSRQ is that the weight-related items are geared for persons desiring thinness. This is problematic in our male patients, who desire muscularity more than they desire thinness (38). We considered using the Body Area Satisfaction Scale section of the MBSRQ alone, as a previous group had done (39), but this was confirmed to be not comprehensive or detailed enough for our patient population. The Body Dysmorphic Disorder Examination was rejected because perceived degree of deformity may not be as relevant in those of our population who present with very real and obvious deformities (40). We preferred the Derriford scale, a landmark attempt at developing a quality-of-life measurement that is condition-specific for a plastic surgery patient. However, it would be an extremely lengthy instrument for a patient with several deformities because the scale is meant for a single region of interest (18, 41, 42).
Some of the instruments we utilized had some less-than- ideal features. If the quality-of-life changes are very specific, the ceiling and floor effects of the SF-36 make measuring improvement beyond particular points of an instrument difficult (8, 43). Although we used HRQOL, a heavily modified version of the SF-36, for our study, it most likely did not improve its sensitivity. Problems finding clothes and problems pursuing leisure activities, problems with body confidence, social embarrassment, difficulty fitting in public transport, and reluctance for intimate relationships are touted as top priorities yet are not measured in most quality-of-life scales (27, 44). We developed the PBSQOL questionnaire as a supplementary measure of quality of life, specifically to address issues most frequently broached in our clinics, and we are currently validating this scale with a larger cohort. Silhouette studies have been in wide use to study current body-size perception and ideal body size. Although the inexact and subjective nature of this method has been criticized (38), the silhouette method is serviceable when studying stability and/or change in body self-perception over time.
In our patient population, patients who had body contouring procedures named thinner silhouettes as their ideals. However, this does not necessarily indicate dissatisfaction. Inspiration hypothesis may apply here, where patients, as they reach their goals, increasingly desire to achieve their most svelte selves (44). Presumably, a highly successful target evokes an achievable possible self that is integrated into one's self-image. Thin media images are encouraging to patients who view thinness as attainable. Subjects reported a more positive self-image post-exposure, suggesting that inspiration hypothesis is more often true than a negative contrast explanation, where a thin media image would deject a non-thin subject. As massive weight loss patients near their target appearance, a superlative possible self may be evoked and integrated into one's current self-image (44, 45), its presence encouraging rather than demoralizing.
Ultimately, we want to develop and use studies that are relevant and specific to this patient population. One scale of interest is the Internalization Subscale of the Sociocultural Attitudes toward Appearances Questionnaire: awareness and internalization subscales (46). Previous studies indicate that internalization of societal emphasis on physical appearance is a stronger predictor of BID than the mere self image or awareness of public standards. Viewing of ideal body images in the media has not only changed ideal body image but has directly increased approval of plastic surgery for image enhancement (46, 47). In our clinics, the majority of our patients at initial consultation expressed general satisfaction with their appearance except for their loose-hanging skin, especially in the abdomen. However, on correction of those specific deformities, more areas of dissatisfaction would often surface. One hypothesis is that as this patient population approaches normalcy in appearance, they become increasingly susceptible to the thinness ideals of the prevailing sociocultural milieu.
We have identified a plastic surgery population whose body image and quality-of-life changes have scarcely been investigated. Obese individuals suffer from disturbed body image and decreased psychosocial function in relation to excess adiposity (48, 49), and how much these parameters shift during the course of weight loss and body contouring is, as yet, unclear. Body image is generally more favorable in healthy and vigorous patients (50), and post-bariatric surgery weight loss patients may gain additional satisfaction from their recent victory over severe obesity and the ensuing healthier lifestyle. Clearly, positive changes in physical appearance and physical effectiveness should influence self-image. Weight control may be good body image therapy (11) for patients before they ever enter a plastic surgery office.
Our study involved a very small population of patients undergoing body contouring after massive weight loss. We recognize that our results are, thus far, introductory and that there is a great need to further develop and validate the questionnaires in larger populations. We aim to test the hypothesis in larger patient samples once we have in our possession a concise and widely validated method of determining body image and quality of life in our population.
A number of practical challenges lie ahead for developers of patient-based outcome measures relevant to post-bariatric surgical weight loss body contouring (51). First, the measures should be amenable to pre- and post-operative administration. Second, for many contouring procedures, the outcome would seldom seem normal because of residual deformities. Third, due to heterogeneity of procedures, time frames of relevance will be highly varied. Despite these methodological difficulties, subjective self-evaluation should be systematically incorporated into the care of the post-bariatric weight loss patients. By identifying the struggles regarding body image and recognizing the hurdles to achieving their optimal quality of life, we can more appropriately assist these patients. Our challenge lies in developing the optimal methods of assessment that elucidate and demystify the clinical evolution of this rapidly expanding population.