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 (5). The abdominal area causes the most problems, followed by the chest and the thighs (5, 6). Excess skin can therefore become a new source of stigma, social isolation and reduced quality of life for these patients (7, 21).
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 (8).
Tobacco smoking is associated with a 2 – 3 times greater risk of post-operative wound complications, infections and delayed healing (22). Preoperative smoking cessation can halve this risk, and the risk is lowest after at least four weeks of abstention from smoking (22). Smoking cessation is therefore an absolute requirement before any type of body contouring surgery (22) – (24).
Prior to plastic surgery, the patient must have good nutritional status, haemoglobin levels > 10 g/100 ml (8, 23) and have a satisfactory level of physical fitness (8, 24). 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 (8, 25).
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 (9, 26). A number of small retrospective observational studies support this view. Considerable evidence suggests that the incidence of serious and less serious complications is roughly twice as high in those with BMI ≥ 30 kg/m² compared to those with BMI < 30 kg/m² (26) – (28).
Results from two major prospective registry studies failed to confirm preoperative BMI as an independent predictor of surgical complications (24, 29). However, the risk of complications did increase with increasing BMI (OR 1.06; 95 % CI 1.0 – 1.1) (24). Overall, we do not believe there are strong scientific grounds for using BMI alone as a tool to assess indication for surgery. If BMI ≥ 30 kg/m² is used as an exclusion criterion for surgical removal of loose skin after weight loss, more than half of patients in need of such treatment could be excluded (17).