A critical literature review: the impact of reconstructive surgery following massive weight loss on patient quality of life

Authors


Jo Gilmartin
School of Healthcare
Baines Wing
University of Leeds
Leeds
LS2, UT
UK
Telephone: +11 3 343 12 54
E-mail: j.gilmartin@leeds.ac.uk

Abstract

gilmartin j (2011) Journal of Nursing and Healthcare of Chronic Illness3, 209–221
A critical literature review: the impact of reconstructive surgery following massive weight loss on patient quality of life

Aim.  To critically review published papers on the impact of reconstructive surgery following weight loss on patient quality of life and identify areas of patient dissatisfaction.

Background.  The global obesity epidemic is a major health problem and a growing number of morbidly obese patients are seeking surgical solutions such as bariatric surgery. Massive weight loss often leads to excess of lax, overstretched skin causing physical dysfunction and psychosocial problems which impact on patient quality of life. Reconstructive surgery is a major growth intervention for body improvement and provides significant functional and aesthetic benefit following such massive loss. However, little collective evidence exists regarding the impact of body contouring on patient quality of life and psychosocial function.

Design.  Literature review conducted between May 2010 and July 2010.

Methods.  Database searches of CINAHL, Psychinfo, EMBASE and the Cochrane library using various keyword combinations related to reconstructive surgery following massive weight loss was performed.

Results.  A total of 10 papers matching the inclusion criteria were identified. The literature revealed that many patients reported an improved quality of life following reconstructive surgery such as improved well-being related to self-image and capacity, and some participants reported dissatisfaction with cosmetic results and health complications.

Conclusion.  Massive weight loss results in excess redundant skin creating physical, functional and psychosocial problems that impact on quality of life. There is ground for believing that possible long-term change in massive weight loss patient management will make its sustained appearance when national guidelines and policy recommend an ‘ideal’ care pathway for patients following reconstructive surgery.

Relevance to clinical practice.  The massive weight population continues to grow globally. Although patients experience a huge accomplishment with successful weight loss, excess skin, physical and psychosocial limitation coupled with a persistently poor body image can adversely affect their quality of life. Hence, quality of life and outcome research is vital in shaping health policy and developing National Service Frameworks impacting on the construction of an ‘ideal’ care pathway for such patients. Therefore, it is crucial that health professionals make critical use of evidence, engage with outcomes research, innovative practice, and challenge idealistic ‘media expectations’. The multidisciplinary team approach is essential in furthering the evolution of novel ideas and offering first class, individualised, long-term care.

Introduction

Obesity is prevalent in our society and evidence suggests that obesity is robustly associated with hypertension, heart disease, stroke, musculoskeletal pain, diabetes, cancer and a poor sense of well-being (Calle et al. 2003, Sarafino 2006). Despite government initiatives for tackling obesity (Walness 2004), National Institute of Clinical Excellence (2006), these messages pointing to healthy eating and lifestyles are frequently ignored. Morbid obesity [grade 111, body mass index (BMI) of 40 and above] is a major challenge and the uptake of bariatric surgery is gaining global momentum, especially for individuals with ‘extensive histories of weight cycling and failed dieting’ (Ogden et al. 2006, p. 289). Although bariatric surgery outcomes show significant improvement in psychosocial function but the initial improvements in mental health and body image did not last (Herpertz et al. 2003, Ogden et al. 2006, Rydén & Togerson 2006, Niego et al. 2007), the resulting redundant skin, however, usually presents new and unanticipated problems, both physical and psychological, posing the uptake of reconstructive surgery as a necessary option. Reconstructive surgery treats both the functional and aesthetic problem of extra skin and in many cases improves patient well-being and quality of life (QoL) (Datta et al. 2006).

A small number of studies investigated body contouring in massive weight loss (MWL) patients focusing on patient satisfaction and/or psychological outcomes or explicitly on surgical outcomes. Massive weight loss is defined as 50% or greater loss of excess weight 45 kg (Shrivastava et al. 2008). After a rapid and MWL there is a sudden change in BMI which leads to skin and soft tissue excess and poor skin tone.

Favre and Egloff (2005) reports case series (2000–2005) amongst 122 patients, who underwent a diverse range of cosmetic surgery procedures following such loss, focusing on patient satisfaction and QoL. The results allude to patient satisfaction. However, the methodology fails to report what instruments were used (if any) to measure patient outcomes. Similarly, Rohrich et al. (2006) retrospective case series (12 years) involving 151 central body lift patients revealed both patient and physician satisfaction. Again, it is not clear what instruments were used (if any) to measure patient outcomes. Throughout this review, it is vital that we critically evaluate evidence, but this must include potentially relevant primary sources of evidence and be collected through appropriate methods of research.

Aim

The purpose of this literature review is to critically appraise published papers on the benefits of reconstructive interventions following MWL surgery on patient QoL and identify areas of patient dissatisfaction.

Methods

The article search was conducted between May 2010 and July 2010 using online databases including CINAHL, EMBASE, Medline, Ovid full text, PsycINFO and Cochrane. Search terms used were: ‘body contouring surgery’, ‘reconstructive surgery AND MWL’, reconstructive AND surgery AND weight loss, ‘QoL after body contouring’, ‘body image and QoL following body contouring’, ‘attitudes to reconstructive surgery after bariatric surgery’. The number of articles retrieved was initially 80 but only 10 met the inclusion criteria outlined in the next section.

Inclusion criteria

The inclusion criteria were as follows: studies needed to be empirical or research data obtained from documents, to have included interventions or procedures specific to body contouring surgery, and or QoL outcomes following reconstructive surgery, and be published in English. To represent the most up-to-date research, the included studies were to be drawn from literature published between 2000–2010. The guidelines suggested by Petticrew and Roberts (2006) influenced the relevance of the included papers. Hence, all the available abstracts were screened for the inclusion criteria.

Exclusion criteria

Studies were excluded if they were published prior to 2000 and were not published in English Papers that focused explicitly on describing surgical procedures or orientated towards body dysmorphic disorder were excluded because they had a tendency to veer away from QoL or psychosocial outcomes. Papers were also excluded if they only alluded to bariatric surgery and not involve patients who underwent body contouring.

Quality appraisal

Whittemore and Knafl (2005) point out that there is no gold standard for evaluating and interpreting quality in research reviews. Nonetheless, Cooper (1989) suggests that extraction of significant methodological characteristics of primary studies could be employed to evaluate overall quality. The notion of critical appraisal is defined by Parkes et al. (2001) as ‘the process of assessing and interpreting evidence systematically considering its validity, results and relevance’. An important feature of critical appraisal is that a good study usually provides sufficient information to help a researcher or health professional judge that it is a good or useful study. To facilitate critical appraisal a published checklist is required, which should consider validity, reliability and applicability of a study (Rees et al. 2010). Indeed, the value of critical appraisal depends on first finding appropriate studies to include.

Included studies were reviewed using questions from the checklists put forward by Rees et al. (2010), Pollock and Beck (2004). Data extracted are summarised in tabular form with regard to the aim of the review and demonstrated in Table 1. The review used studies from different settings and countries. Four studies were conducted in the USA and one undertaken in Brazil. Five were carried out in Europe, which included France, Italy (2), Holland and Switzerland. This highlights not only a general lack of studies conducted in the UK but also in Australia.

Table 1.   Characteristics of the included studies
Author/year/locationAim or questionDesign/methodsSample size/response rateMajor findingsStudy rigour
  1. BMI, body metabolic index; MWL, massive weight loss.

Au et al. 2008, Philadelphia, USATo identify predictors of poor outcomes/complications of body contouring that would help guide patient selectionRetrospective random chart review on patients who underwent body contouring from 1993–2002. Age, gender & BMI were obtained= 139 patient charts were reviewed. (eight men & 121 women). Age range 32–35 years. 33 patients had undergone gastric bypass surgery & others lost weight through diet & exerciseThe percentage of minor complications (infection (14·7%), seroma/hematoma (6·2%), minor wound (0·8%) increased from 3·3% in the ideal weight group to 46·9% in the severely morbidly obese group. Similarly, the major complications (significant wound (14·7%), dehiscence (2·3%) re-operation (4%), tissue necrosis (2·3%), death (0·8) increased from 6·6% in the ideal weight group to 43·7% in the severely morbidly obese groupStrengths
That increasing BMI in MWL patients is linked to increased occurrence of complications after body contouring procedures
Limitations
The research methods are poorly articulated. Only random chart review employed
Cintra et al. 2008,Sáo Paulo, BrazilTo explore quality of life after abdominoplasty in women after bariatric surgeryExperimental
The Adaptative Operationalised Diagnostic Scale in a semi-structured interview format
= 16, 100% female, age 40·1 ± 8·0 years. Submitted to standard or combined circumferential abdominoplastySelf-esteem was adequate in 87·5%, 87·5% had a very good self-image and 68·8% declared freedom from dependence or disability and a better sex life. The most significant complication was serous fluid collection (18·8%). The results also highlight that 37·5% of participants had moderate maladaptation (6·3%) or severe maladaptation (6·3%) or very severe madadaptation (6·3%)Strengths
Improved quality of life identified
Limitations
The maladaptation features are downplayed in this study, failing to address potential adverse outcomes of abdominoplasty. More specifically, the sample size is very small & only included female patients
De Kerviler et al. 2009, SwitzerlandTo investigate & define risk factors for complications in reconstructive body contouring surgery following different methods of massive weight reductionRetrospective data & variables were collected from patient’s medical records. Massive weight loss was achieved through bariatric surgery in 59·6% (= 62) of patients & dietetically in 40·4% (= 42)= 104, 17 patients were male & 87 were female. The mean age was 47·9 years and they had undergone reconstructive body contouring between January 2002 and June 2007Dietetically achieved excess body weight index loss was 94·2% & in this cohort higher than surgically induced reduction 80·80% (< 0·01). Distribution of complications included 48% wound dehiscence, 18% seroma, 9% tissue necrosis, 9% wound infection & 16 haematoma with an overall observed 26·9% complication rateStrengths
Bariatric surgery does not increase risk for complications in subsequent body contouring procedures when compared to massive dietetic weight reduction
Limitations
Retrospective design limits detailed data acquisition. Patient numbers are limited due to a single centre database
Lazar et al. 2009, Rouen, FranceTo present surgical and psychological evaluations of 41 patients who underwent abdomonoplasty after major weight lossRetrospective
Systematic review of patient medical files, two separate surgical and psychological examinations, and two questionnaires
= 41, 32 female & nine male who requested abdominoplasty after an average weight loss of 40·2 kg (range 21–58) and who underwent surgery between 1998–200284·6% have improved QoL; 86·5% have improved psychological status; 74% have better sexual relations; 53·9% admit liking their body; 76·9% are satisfied with the results of the abdominoplasty: and 96·1% would be willing to undergo abdominoplasty againStrengths
Improved quality of life, psychological well-being, familial and social functioning
Limitations
Small group of patients
Of the two specific questionnaires one appears to be unvalidated
Migliori et al. 2006,Genova, ItalyTo identify quality of life outcomes following body contouring after bilopancreatic diversionRetrospective
Review of patient medical notes from 2001–2006
= 176 patients who underwent body contouring procedures after prior biliopancreatic diversionOverall, the majority of patients had an improved quality of life. Higher rates of positive thinking. Body image greatly improved. Improvement in life relationships, and sexual life resumptions or improvementStrengths
Inclusion of a group of patients who underwent a range of procedures e.g. brachioplasty, thigh-lift, mastoplasty, abdimnoplasty & torsoplasty
Limitations
This study is preoccupied with surgical methods, extent and typology of operations with no clear indication if any specific instruments were used to measure patient outcomes
Mitchell et al. 2008, North Dakota, USATo examine the use of body contouring, or the desire for such surgery, and current satisfaction with various body areasRetrospective study of patients who had undergone Roux-en-Y gastric bypass 6–10 years prior to body contouring.
Post-Bariatric Surgery Appearance Questionnaire
= 70 patients. Response rate was 28% (70 of 250). The majority were Caucasian (97%) and female (84·3%). The mean BMI at follow up was 34·1 kg/m2 & the mean age was 49·9 ± 9·2 years33 patients reported having undergone a total of 38 body contouring procedures. The majority of the patients desired such procedures, particularly in areas such as waist/abdomen, upper arms, chest/breasts. Participant’s evaluation was mixed – with particular dissatisfaction noted regarding the thighs, waist/abdomen, upper arms, & chest breastStrengths
The majority desired the body contouring procedures. Use of validated questionnaire
Limitations
Low response rate; one-third who responded perhaps experienced body appearance problems. All participants had received bariatric surgery from one surgeon; this may have influenced cosmetic outcome. Limited data collected – no interviews
Mustoe 2006, Chicago, USATo identify outcomes from outpatient and inpatient abdominoplastyRetrospective series of consecutive patients who underwent abdominoplasty= 69 (32 outpatients and 37 inpatients)The most common complication observed was seroma, which occurred in 18% of the inpatients & 24% of the outpatients. Five of the 69 patients were treated with cloxacillin for presumed wound infection. Overall, the infection rate was low (2·0%)Strengths
Validates the use of outpatient abdominoplasty
Limitations
Methodology is poorly articulated. Case note review was the only approach utilised. Sample characteristics are not drawn out
Pecori et al. 2007,Genoa, ItalyTo ascertain if the attitude to body weight & shape of individuals asking for aesthetic surgery after massive weight loss is still compromised & if plastic surgery procedures are effective in improving body image constructExperimental
Cross-sectional study using body image attitude questionnaires- body uneasiness test (BUT)
= 20 morbidly obese women prior to bilopancreatic diversion (BPD) (OB group). = 20 postobese women at greater than two years following BPD (POST-group), = 10 postobese women following BPD who required cosmetic procedure (POST-A group), 10 postobese women after BPD & subsequent cosmetic surgery (Post-B group) & 20 healthy lean controlsThe body uneasiness subscale scores, for the postobese individuals (Post-group), showed markedly lower mean score values than for the obese patients, except for the ‘avoidance’& the ‘compulsive self-monitoring’ scales.
In the postobese individuals who requested body-contouring procedures (POST-A group), The BUT subscales assessing body uneasiness were essentially similar to those recorded in the obese patients & higher than those in the postobese group who did not request cosmetic surgery (POST-group). In the POST-B group, the mean score value of all BUT subscales assessing body uneasiness were similar to those observed in the subjects submitted to BPD who did not request cosmetic surgery
Strengths
In the participants at long-term follow-up following BPD with a steadily reduced body weight greater than two years, the BUT scores were markedly lower than those observed in severely obese patients prior to BPD
Limitations
The data obtained in this cross-sectional study have to be regarded with caution: the phenomenon presented could be simply a chance finding. The sample size is small
Song et al. 2006, Pennsylvania, USATo study body perception and ideals, condition-specific and general quality of life, and mood stabilityPatients were surveyed at the following time points: prebody contouring & 3–6 months postbody contouring using the following instruments:
Pictorial Body Image Assessment (PBIA), Body Image & Satisfaction Assessment (BISA), Current Body Image Assessment (CBIA), HRQOL survey revised version of Beck’s inventory to assess mood
= 18 patients who underwent both bariatric surgery & body contouring procedures were surveyed. Mean age was 46 ± 10 years. 16 were women and two were men15% reported no history of depression, and 50% reported depression under control with pharmacological treatment. Body contouring improved PBSQOL scores significantly, with a mean 55% overall improvement in quality of life measurements = 13, < 0·01.
The top three areas of distress at 6 months after body contouring – medial thigh (54%), flanks (36%), and hips/outer thigh (27%)
Strengths
Quality of life was greatly enhanced after body contouring. Three validated instruments were used
Limitations
Small sample size
40 participants were recruited & obtained complete data from 18. Two instruments were developed for this study – BISA & CBIA. Although the majority had a fairly prominent history of depression, mood fluctuations were not drawn out
Van der Beek et al. 2010, The NetherlandsTo evaluate the results of reconstructive surgery following weight loss surgery, focusing on quality of lifeRetrospective Evaluation
Quantitative
Quality of life measurements
Obesity Psychosocial State Questionnaire
= 2 males & 41 females who underwent reconstructive surgery. Mean age was 41·5 years (range 23–60 years) response rate = 70·5%Reconstructive
Surgery improved physical functioning & patients felt healthier (< 0·001). Patients also experienced less depressive symptoms (< 0·001), and fewer problems of intimacy & sexuality (< 0·001). There was a significant difference in self-efficacy towards eating before and after reconstructive surgery (< 0·001); patients had more problems coping with their eating behaviour after surgery
Strengths
Psychosocial state questionnaire – although not validated proved satisfactory. Quality of life outcomes identified
Limitations
Preoperative quality of life was measured retrospectively Small sample size Mostly women

The following sections will offer a more in-depth critique of individual papers focusing on the research process employed.

Results

The design of a study provides a plan for data collection and analysis being portrayed as the structure within which the study is implemented. Seven of the studies (Au et al. 2008, De Kerviler et al. 2009, Lazar et al. 2009, Migliori et al. 2006, Mitchell et al. 2008, Mustoe 2006, Van der Beek et al. 2010) utilised a retrospective approach, which frequently uses existing data that has been recorded for reasons other than research. In healthcare these are often called ‘chart reviews’ because the data source is the medical record, the majority of the studies using a case series approach. For instance, Au et al. (2008) undertook a retrospective random chart review on patients who underwent body contouring from 1993–2002. Mustoe (2006) too carried out a retrospective series of consecutive patients who underwent abdominoplasty. Some researchers view retrospective studies as ‘quick and dirty’ because data are quickly gleaned from existing records to answer questions. Nonetheless, other retrospective studies in this review used a more scientific approach employing questionnaire and QoL instruments for data collection. For example, Van der Beek et al. (2010) measured the actual psycho-social status of reconstructive surgery on QoL by utilising the obesity psycho-social state questionnaire (OPSQ). Mitchell et al. (2008) also obtained retrospective data by using a post-bariatric surgery appearance questionnaire especially developed for their study. A few studies employed a prospective approach (Pecori et al. 2007, Cintra et al. 2008), comparing individuals in relation to personal attribute ‘variables’ affecting QoL (Polit & Beck 2006).

Two particular studies employed an experimental design (Pecori et al. 2007, Cintra et al. 2008), Song et al. (2006) utilised a survey approach. Cintra et al. (2008) employed a simple after-only design, frequently referred to as a posttest-only design because data on the dependent variable are collected only once to measure QoL after abdominoplasty. In contrast, Pecori et al. (2007) employed a pretest-posttest experimental design. Data collection from 20 morbidly obese women occurred prior to bilopancreatic diversion (BPD) and at a few different time points after the intervention. Song et al. (2006) employed a sample survey approach amongst 18 patients at different time points: prebody and 3–6 months postbody contouring to assess body perception and ideals, QoL and mood. The greatest advantage of survey research is its flexibility and broadness of scope and whilst such research provides important data on QoL outcomes, the data obtained in most surveys tend to be fairly superficial.

Sampling

The majority of the surveys identified a sampling frame detailing the hospitals, patients, types of surgical procedure and the gender and age range of the participants. The type of sampling is well articulated in some studies – e.g. probability sampling (Procter et al. 2010), although this can only be used when an accurate and up-to-date sampling frame is available. Five studies employed probability sampling (Song et al. 2006, Pecori et al. 2007, Cintra et al. 2008, Mitchell et al. 2008, Van der Beek et al. 2010), the strength of such an approach being that it generates a representative sample. In these studies, the sample size ranged from 250 participants (Mitchell et al. 2008) to 16 (Cintra et al. 2008). However, only 70 responded and completed data collection in the Mitchell et al. (2008) study. Bias can be introduced if sampling strategies fail to recruit a large enough sample size to generate statistically significant results (Polit & Beck 2006), but overall, most studies only had a small sample size, mainly of women, with very few male participants.

In contrast, the other five studies did not draw out a clear sampling strategy. All appeared to employ a retrospective review of medical notes identifying time frames and patient groups involved. One study undertaken by Lazar et al. (2009) undertook a systematic review of patient medical notes involving 41 patients (32 female and nine male), two separate surgical and psychological examinations and two separate questionnaires. Again, of the studies that utilised a review of medical notes the groups were mostly women, age range 32–57 years. Various discrepancies exist between the studies under review in relation to the representativeness and size of samples, and the strategies employed to minimise the possibility of these features biassing the results. The potential for these to adversely impact on the results depends on the approach taken to data collection and statistical analysis (Polit and Beck 2006) which are also addressed in this paper.

Data collection methods

Lazar et al. (2009), Mitchell et al. (2008), Pecori et al. (2007), Song et al. (2006), Van der Beek et al. (2010) used questionnaires to gather data; Cintra et al. (2008) employed the Adaptative Operationalised Diagnostic Scale (AODS) in a semi-structured interview format. Au et al. (2008), De Kerviler et al. (2009), Migliori et al. (2006), Mustoe (2006) gathered data from patient records including variables such as gender, age, BMI before and after weight reduction, method of weight reduction (dietetic vs. bariatric surgery), blood loss and outcome variables. There are two major sources of bias in records including ‘selective deposit’ and ‘selective survival’ (Polit & Beck 2006, p. 403). If the available records are not the entire set, researchers must address the question of how representative existing records are, and in all the papers that used this specific approach several disadvantages surrounding the use of medical records have been overlooked.

The instruments or tools used are a very important way of promoting a study’s aims or objectives, and of ensuring the reliability and validity of its findings (Bowling 2004). Five of the studies used measurement scale instruments consisting of multiple items designed to shed light on subject functioning (QoL scales) and help discriminate levels of functioning between sample groups. Van der Beek et al. (2010) employed the OPSQ using a Likert type scale. Participants rate the series of preset statements representing different viewpoints along a continuum (Polit & Beck 2006). Song et al. (2006) used six instruments associated with the multi-dimensional concept of QoL including the body image satisfaction assessment (BISA) questionnaire, a current body image assessment (CBIA) instrument, and the post-bariatric surgery quality of life (PBSQOL) survey that were developed for this particular study. Mitchell et al. (2008) too used a post-bariatric surgery appearance questionnaire developed for their study. However, the reliability and validity of such scales can vary according to structural design and the complexity and subtlety of questions (Bowling 2004). Scale reliability and validity were not overtly addressed by Song et al. (2006) nor was any attempt made to test the newly developed instruments ability to maintain reliability when used in different populations.

Data analysis

Au et al. (2008), Song et al. (2006), Pecori et al. (2007), Van der Beek et al. (2010), De Kerviler et al. (2009), Cintra et al. (2008) used bivariate non-parametric methods of data analysis such as t-tests, Mann–Whitney, Fisher’s exact, Krusal–Wallis tests and Pearson and Mantel–Haenszel χ2 tests. As such, bivariate analysis was appropriate to the research aims of comparing cases with comparisons/controls. Van der Beek et al. (2010) also used multivariate analysis, a process allowing analysis of relationships between three or more variables. This is a more sophisticated analysis, increasing the rigour and quality of the evidence (Polit and Beck, 2006). Cintra et al. (2008) present the values for the five levels of adaptation after abdominoplasty, from adequate (level 1) to very severe maladaptation (level 5), using a Likert type scale. Values are shown as the mean ± SD. Comparison of BMI before and after the operation was undertaken by paired two-tailed Student’s t-test to a significant level of 5% (< 0·05). However, Bowling (2004) argues that mean values may distort results by disproportionately reflecting a small number of outlying values. To address this, alongside each mean value Cintra et al. (2008), Pecori et al. (2007) present the SD, allowing readers to analyse how closely mean values reflect the full distribution of scores.

To further quantify the association between complications and weight groups (e.g. ideal, obesity, morbid obesity or severe morbid obesity), Au et al. (2008) used three logistic regression models to predict minor or major complications with weight group as the only predictor.

Key findings

Seven of the studies reviewed reported that reconstructive surgery was 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, Lazar et al. 2009, Van der Beek et al. 2010). The statistically significant domains will be emphasised in the following section with reference to three key themes: improved QoL, complications following body contouring and dissatisfaction from reconstructive surgery.

Improved quality of life

Cintra et al. (2008) reported outstanding responses to the social and cultural performance domains where 81·3% of patients had excellent adaptation. Other significant psychosocial sub-domains reported that 87·5% had a positive self-esteem, 68·5% declared freedom from dependence or disability and a better sex life and 87·5% had a very good self-image. Similarly, Lazar et al. (2009) found that 84·6% had improved QoL; the following domains were emphasised, sexual relations (74%), aesthetics (79·5%), dressing (84·8%), psychological status (86·5%), and current life (100%). Migliori et al. (2006) too reported that 99% of the sample had an improved QoL such as positive thinking, body image satisfaction, sexual life resumption or improvement. However, statistically significant differences between cases and comparisons in dimensions of function and well-being are not described in detail. Pecori et al. (2007) also found that morbidly obese patients who underwent body contouring following BPD had lower scores in body uneasiness. However, Pecori et al. (2007) found no statistically significant difference between 10 postobese women at greater than two years following BPD (POST-A group) that asked for body contouring but did not under go any procedures and 10 postobese women after BPD who underwent cosmetic or body contouring procedures (POST-B group) at greater than one year (13–22 months) following BPD.

In contrast, Song et al. (2006) found that body contouring improved QoL significantly, with a mean 55% overall improvement in QoL measurements (= 13), p < 0·01). Mitchell et al. (2008) evaluated body contouring and found some congruency between the perceptions of attractiveness and improved quality QoL but no scores are evident. Moreover, Van der Beek et al. (2010) too found a striking improvement in QoL in several domains including improved physical functioning and patients feeling healthier (p < 0·01), improved mental well-being and confidence (p < 0·01), fewer problems of intimacy and sexuality (p < 0·01), improved self-efficacy towards eating (p < 0·01) and improved social acceptance (p < 0·01). The reliability and validity of the findings of all seven studies are arguably contingent on the robustness of their study design, validated tools used and data analysis. However, QoL scores were generally higher within the body contouring populations.

Complications following body contouring

Five of the 10 studies reviewed alluded to complications but this variable was not negatively associated with QoL. Au et al. (2008) reported that increasing BMI in MWL patients is linked to increased occurrence of complications after body contouring procedures. The percentage of minor complications – infection (14·7%), seroma/haematoma (6·2%), minor wound (0·8%) – increased from 3·3% in the ideal weight group to 46·9% in the severely morbidly obese group. Similarly, the major complications – significant wound (14·7%), dehiscence (2·3%) re-operation (4%), tissue necrosis (2·3%), death (0·8) – increased from 6·6% in the ideal weight group to 43·7% in the severely morbidly obese group. Cintra et al. (2008) also found the most significant complication was serous fluid collection (18·8%) and anaemia because of blood loss (6·3%).

Furthermore, De Kerviler et al. (2009) reported the distribution of complications, including 48% wound dehiscence, 18% seroma, 9% tissue necrosis, 9% wound infection and 16% haematoma with an overall observed 26·9% complication rate. Mustoe (2006) too found seroma to be the most common complication, which occurred in 18% of the inpatients and 24% of the outpatients. Five of the 69 patients were reported as being treated with Cloxacillin for the presumed wound infection. However, Van der Beek et al. (2010) found that the overall complication rate was 27·9% but the researchers have downplayed the typology of complications failing to report specific details The remarkable fact is that the high percentage of complications (asserted by Van der Beek et al. 2010) did not appear to influence patient satisfaction.

Dissatisfaction from reconstructive surgery

Patient dissatisfaction from reconstructive surgery only surfaced in a few of the studies. According to Van der Beek et al. (2010) eight patients (18·6%) reported being dissatisfied with the proportions of their body after the operation and especially with the occurrence of redundant skin edges or bunching of skin at the tail end of a long wound (dog-ears in the scar). They also reported that some patients had high expectations about the result based on internet examples and were disappointed with the result of their own operation.

Mitchell et al. (2008) too reported dissatisfaction with skin breakdown, most commonly reported being sores, rashes and skin breakdown in the waist/abdomen area (25%), chest/breasts (19%), thighs (16%) and rear/buttocks area (7%). The significant fact is that the subject’s evaluation of the sites that have undergone body contouring is mixed (Mitchell et al. 2008), some finding areas attractive and others unattractive, with much variability. Similarly, Song et al. (2006) reported that the most significant areas of distress at six months after body contouring were medial thigh (54%), flanks (36%) and hips/outer thigh (27%).

Discussion

The role of reconstructive surgery following weight loss is still underestimated by some medical specialists and the National Health Service in the United Kingdom (UK). Only 62% of primary care trusts allow reconstructive surgery without exceptional circumstances because it is not perceived as a priority. Adequate National Health Service funding is not available to allow a fairer distribution of this treatment to the public. Currently, around 70–80% of all body contouring procedures are performed in the private sector which is not ideal for a socialised healthcare system (NHS). New ideas to allow more NHS funding such as part payment should be considered. Furthermore, there are no policies and national guidelines that recommend an ‘ideal’ care pathway for patients requiring reconstructive surgery following MWL.

There is some ground for believing that possible long-term change in MWL patient management will make its sustained appearance when some of the body image, self-esteem, mental health and functional issues begin to be addressed more systematically. Those health professionals who are strongly committed to delivering good long-term care, and who are disposed to optimism about their work, are inclined to perceive the current culture of care as ‘paradigmatically wrong’. That is to say, the framework of care within which MWL patients are managed does not place a high premium on body contouring. The main data reported in this paper, obtained from patients who mainly had a rich experience with long-term care following MWL, emphasise that QoL is important. These measures enable insight into the health needs of such populations; therefore there is an ongoing need to consider the part played by QoL research in implementing health strategies such as National Service Frameworks and an ‘ideal’ care pathway for this particular client group.

Reconstructive surgery patients are protected to some degree globally given that the actions of all health professionals are circumscribed by criminal law. However, it is significantly more likely that liability for negligent performance of surgery would be pursued in tort law. Consequently, any plastic surgeon who intentionally or recklessly causes injury will be liable to a criminal prosecution for assault or battery under the Offences Against the person Act 1861, sections 18–20. More specifically reconstructive surgery is governed in the UK by the National Health Service Act 2006 and the Health and Social Care Bill (2008); however, many body-contouring procedures are undertaken in the private sector and the implementation and supervision of the aforementioned regulation remains in the hands of private surgeons and the clinics’ regime of self-regulation. Unsurprisingly, negligence and inadequate standards such as lack of infection control policy and doctors not having specialist training are frequently reported in both national and international newspapers. The deficits of regulation were made abundantly and explicitly clear by Latham (2008). Therefore, it is crucial that the provision of long-term care consistently considers and embraces the prevailing seriousness of implementing effective regulation. More poignantly, regulation points to forms of good practice that may be developed with confidence.

The major area of patient dissatisfaction from reconstructive surgery reported in this review alluded to ‘patient expectation’, ‘issues about skin breakdown’, ‘scar asymmetry’ and ‘wound healing problems’. Song et al. (2006) suggest, largely on the basis of their work with body contouring patients, that it is important for patients to understand that after correcting desired deformities, new deformities that were not previously appreciated may become more noticeable. Careful preoperative analysis of the nutritional status, stable weight, patient expectation and goals might allow the creation of an appropriate plan of action and the staging of procedures. Moreover, many centres of excellence provide comprehensive care to patients including the education of patients about realistic outcomes. As the body contouring population continues to grow, patient management should also include innovative research to identify novel treatment modalities and provide evidence-based intervention.

A further dissatisfaction variable put forward by Van der Beek et al. (2010) alludes to eight patients (18·6%) being dissatisfied with the proportions of their body after the operation and especially with the occurrence of redundant skin or skin deformity (dog ears in the scar). They trace the cause and growth of some disturbance to ‘internet’ examples. Indeed, one of the hallmarks of contemporary western culture is its promotion of an ‘internet ideology’ of ‘plastic surgery’ procedures, that often devalues or occludes the fact that individual tolerance and capacity for healing varies greatly. Typically websites generate bodies of knowledge that are easily accessible and multi-layered in representation including sound, graphic, video and text is possible in one message, thus integrating advertising with entertainment and information (Wykes & Gunter 2006). According to Gilmartin (2009) only a small number of individuals question the authority of the media and the idealistic aspects of its interjects. It is vital that health professionals challenge the pathological implications of body contouring ideals portrayed in the media, invite patients to challenge its authoritarian, disempowering nature, and to help them construct a fresh understanding of what a healthy, cherished sense of body image might be. Health professionals, being more realistic, are in a better position for meeting the long-term needs of patients in psychologically legitimate ways.

Limitations

There was a lack of systematic reviews and randomised controlled trials for inclusion in this review. More rigorous designs investigating the impact of reconstructive surgery following MWL on patient QoL are needed because many of the studies did not appear to incorporate validated instruments.

Overall, there is a scarcity of high-level evidence in regard to QoL outcomes from body contouring procedures. Nonetheless, the comprehensive nature of the review and the consistent findings across studies support the conclusion.

Relevance to clinical practice

In order to accept that body contouring and patient education is now an important healthcare issue; healthcare professionals require new ways of addressing patient need to enhance QoL outcomes. First, one crucial factor is the development of a National Service Frameworks and an ‘ideal’ care pathway to empower this particular client group. Second, it is vital is to educate patients about deciphering appropriate sources of information required to make a properly informed decision about whether to go ahead consider the risks involved and manage expectations of the results the procedure may bring. This might require health professionals to challenge idealistic ‘media expectations’ and communicate more openly and dynamically with patients. Third, it is also important for health professionals to emphasise patient choice, and a stronger patient voice to create autonomy enhancing conditions for patients undergoing this form of surgery, that is gaining global momentum.

Conclusion

There is no doubt that obesity is a complex multifactorial condition that requires a specific knowledge to optimise patient care and safety following body-contouring intervention. It is, however, reasonably certain according to the evidence presented in this paper that QoL enhancement of the kind described does take place in some patients.

Central government in the UK is hugely concerned with developing drivers and policies to reduce obesity at the present time. Counter to this, however, it must be said there is a remarkable deficit in national policy and guidelines for managing patient care in regard to reconstructive surgery following MWL. The field of body contouring continues to grow and more empirical research, collective experience, local, national and international guidelines need to be urgently developed to optimise care in this patient population; in addition, more vigorous design is needed in such research to influence and shape health policy.

Contributions

Study design: JG; data collection: JG; data analysis: JG and manuscript preparation: JG, JW.

Conflict of interests

There is no conflict of interest with respect to the preparation and content of this paper.

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