One third of the UK population is now clinically obese, and more and more people are seeking bariatric, or weight loss, surgery. Bariatric surgery is usually sought by individuals who have been unable to lose weight through diet or exercise. The procedures involved, such as gastric bands and bypasses, work by modifying the gastrointestinal tract to reduce the patient’s nutrient intake and absorption, leading to substantial weight loss. The majority of people who seek body reshaping have been through bariatric surgery, although some will have lost weight naturally through diet or exercise programmes. However, body reshaping is not an easy, quick-fix intervention – four or more operations may be required to improve body shape, with a three-month interval between each procedure. There are also a number of prerequisites in terms of patient health and fitness. You must be able to demonstrate that you are in a good general health, and that your weight has been stable for at least one year. Patients also need to be realistic in their expectations. Both functionally and aesthetically, body reshaping can bring about huge improvements, but it cannot set the clock back or restore a once perfect figure. You must be prepared to accept the significant scarring that will result.
2. Areas most commonly affected and operated on
The areas of the body most commonly affected by post-weight loss tissue overhang are:
Abdomen, flanks and buttocks
Breasts and back
3. What surgery is available, and what techniques are involved?
Excess abdominal tissue can be removed by a procedure known as an abdominoplasty. If the excess tissue also affects the buttocks and outer thighs, another procedure known as a lower body lift may be required. Before a body lift operation, the surgeon will make markings on a patient’s trunk to guide them as to how much tissue to remove. During the operation, overhanging abdominal skin and the folds from the lower back are excised. As the excision wounds are closed, the buttocks and thighs are lifted by upward traction on the remaining tissue. In some cases, it is possible to use the excess tissue to boost and augment the buttocks. The stomach muscles can also be tightened at the same time. This is an extensive procedure that typically takes over four hours to complete. Several surgical drains are left in the wounds to avoid any internal collection of fluid. Elasticised abdominal support may be advised following the operation, and patients usually need to stay in hospital for between two and four days.
Loose breast tissue can be improved by lifting and reshaping the existing fatty tissue and trimming the excess skin. The procedure, known as a mastopexy, results in an inverted T- shaped scar; this scar is positioned around and under the nipple within the lower breast fold. Excess tissue from the upper back can sometimes be used to augment empty breasts. Patients having their breast tissue lifted and reshaped may need to have surgical drains inserted, and will need to stay in hospital for one-to-two days. More information on breast surgery can be found here.
For loose skin affecting the upper arms, a procedure known as an arm lift, or a brachioplasty, can be performed. During the operation, the surgeon removes the excess skin and fat by a long incision extending from the elbow to the armpit. The skin edges are then stitched together and attempts are made to hide the scar by following the line of an imaginary shirt seam. This procedure may be combined with liposuction or breast surgery.
Excess loose skin from around the thighs can be corrected by an operation known as a medial thigh lift. During the procedure, a marked area is treated with liposuction and the layers of excess skin and fat are removed. The skin edges are then stitched together, with a scar running from knee to groin on the inside of the thigh. In some cases, a surgical drain may be required.
4. Is this surgery available on the NHS?
In some parts of England the local Primary Care Trust (PCT) will allow consultations and operations for persons unhappy with the appearance of their body following weight loss. These decisions vary from region to region. Different rules also apply in Wales, Scotland and Northern Ireland. Your GP or PCT in your area will be able to tell you about the local rules that apply for where you live. BAPRAS is unhappy that this type of postcode rationing occurs and has worked with the Department of Health in drawing up guidelines for commissioning cosmetic procedures on the NHS. If you find that body reshaping procedures are not available on the NHS in your area you will have to consult a plastic surgeon as a private patient and pay for the operations yourself.
5. What should I do if I want to consult a plastic surgeon?
We would strongly advise that you consult your GP if you are considering body reshaping surgery. They will be able to refer you to a local plastic surgeon to discuss your options. If you have access to NHS treatment this will be at a plastic surgery outpatient clinic in a nearby NHS hospital. In some areas there will be a surgeon who is part of an established, multidisciplinary bariatric team that can provide appropriate care, with nutritional and psychological support if required. Your GP can also refer you to a plastic surgeon as a private patient. Some patients will choose to approach a private hospital or clinic themselves. If you do this you should ensure that your initial consultation will be with the surgeon who will be doing the operation. You should expect to pay for this consultation. You should check in advance that the surgeon is on the specialist register of the GMC in plastic surgery. You can check here to see if they are a full member of BAPRAS.
At your first consultation you will be asked what is bothering you about your appearance, which areas trouble you the most, and about your expected outcome from the surgery. A patient’s general fitness will also be evaluated. You will be examined and discussion will follow about which type of procedure might be appropriate. Body reshaping is not a standardised procedure. It is a highly individualised treatment where operations are tailored to a patient’s wishes and needs. Before any surgical work takes place, patients will talk at length with their surgeon to address their main concerns, identify their priorities and establish what can be achieved.
If you are considered suitable you will be told about the operations, the expected outcomes and possible risks and complications. For patients who are eligible, NHS treatment is entirely free.
Private patients should be given a ‘cooling-off’ period before booking surgery, and will usually have a second consultation. You will be sent a quote regarding the cost. You should avoid any deal in which you are asked to pay any form of non-returnable deposit. Most hospitals will offer a package price that covers the cost of treating any complications arising in the initial weeks after the operation.
6. What should I expect in terms of treatment, procedures and outcomes?
Body reshaping may entail a number of different operations each tailored to the needs of that particular patient. For this reason it is impossible to generalise about the nature and effects of the surgery. Specific information about abdominoplasty is available in that section, although more extensive scars will often be needed in massive weight loss patients. Mastopexy is also described elsewhere.
Arm reduction and thigh reduction are both general anaesthetic procedures. You will be admitted on the day of surgery, and will stay one or two nights in hospital. You will have some dressings in place and usually some drains (plastic tubes attached to suction bottles). The drains will usually be removed before you go home. You will be given instructions about your dressings and stitches when you go home. Most surgeons will use mostly dissolving stitches, but some stitches might need to be removed. Post-operative pain in these procedures is easily controlled. Patients will be mobile from day one and should be back to full exercise within four weeks. Patients are recommended to take at least four weeks off work immediately after the operation in order to ensure they recuperate fully. These timings are approximate and depend on what exactly is done; also some people recover quicker than others. Some patients will have combinations of operations done at the same time. All body reshaping surgery results in significant scarring although the nature of the scars will depend on the technique that has been used. Scars tend to be quite red and raised in the first six weeks, changing over next six months or so and then fading to white. Most patients will form good quality scars over time, but occasionally and unpredictably some patients will get red lumpy scars that do not improve.
7. What complications can occur?
Whilst these operations are generally regarded to be highly successful, there are various negatives and complications that patients need to consider. Body reshaping procedures are major operations and you must be prepared for the process and recovery period. Most patients are delighted with the physical and cosmetic improvements that the surgery brings. However, it is impossible to guarantee that every patient will be completely satisfied with the result. There will be minor asymmetries in respect of the scars, and possibly residual bulges. A perfect shape cannot be restored after massive weight loss. Occasionally patients will bleed immediately after the operation and need to go back to the operating room for this to be dealt with. Wound healing problems can occur. Most wound problems are minor and can be managed with simple dressings, however more major wound problems can arise such as infections, skin loss, wound separation and delayed healing. Wound problems, if they occur, can delay your recovery and result in worse scarring. In some patients fluid will collect in the in the region of the operation. If this occurs it needs to be removed using a needle, this is done in the outpatient clinic. All patients can expect alteration in the feeling of the skin in the area of the operation which is usually permanent. These operations carry a risk of blood clots in the legs and possibly the lungs. Various precautions are taken to limit this risk but if a blood clot occurs, treatment with blood thinning medication will be needed for several months. Blood clots in the lungs can be serious.
8. Where should I go for more information and support?
BAPRAS’ cosmetic surgery checklist; Department of Health – Cosmetic surgery