weight reduction following abdominoplasty a.36

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COSMETIC

Weight Reduction following Abdominoplasty: A Retrospective Case Review Pilot Study

Jennifer C. Fuller, M.A.Catherine N. Nguyen, B.A.Rex E. Moulton-Barrett, M.D.

Alameda, Los Angeles, and

San Jose, Calif.

Background: The question of whether or not abdominoplasty is associated withpermanent weight reduction remains controversial. In coalition, should ab-dominoplasty be used as an adjunct for weight reduction in the overweight/obese patient?Methods: This retrospective patient case series attempts to determine the most important factors associated with weight reduction.Results: All patients undergoing abdominoplasty had weight loss beyond that of their resected pannus, with a minimum body mass index reached 11.6 Ϯ 1.7

weeks after surgery. Weight loss is attributed to an increase in satiety by 75percent (n ϭ 15) of patients. Preoperative body mass index greater than or equalto 24.5 kg/m2 can be used to predict long-term weight loss with a sensitivity andspecificity of 92.9 percent and 83.3 percent, respectively. Patients above this

threshold achieved significantly more weight loss (Ϫ4.5Ϯ 1.4 percent body massindex) at 1 year compared with their lower body mass index counterparts ( p ϭ0.014), as did those with pannus resections weighing greater than 4.5 lb ( p ϭ0.01).Conclusions: Abdominoplasty performed on patients with a body mass indexgreater than 24.5 kg/m2 appears to be linked to sustained weight loss at 1 year.Satiety appears to be a prominent contributing factor, as does the amount of fat resected. Possible neurocrine mechanisms are discussed. (Plast. Reconstr. Surg.131: 238e, 2013.)

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The prevalence of obesity, defined by the Na-tional Institutes of Health as a body massindex of 30 kg/m2or greater,1 has more than

doubled in the United States since 1980.2 Accord-ing to a recent National Health and NutritionExamination Survey, a staggering 33.3 percent of adult men and 35.3 percent of adult women in theUnited States are currently considered obese.2

Obesity is caused by a long-term positive energy balance where energy intake is greater than itsexpenditure. With portion sizes and consumptionof high-calorie foods continuing to increase andphysical activity on the decline, it is not surprisingthat the rate of obesity continues to climb. Theobesity epidemic presents a major health concern,

as it increases the risk of many diseases and healthconditions, including but not limited to sleepapnea, diabetes mellitus, hypertension, osteoar-thritis, dyslipidemia, certain types of cancers,gallbladder disease, stroke, and coronary heart disease.3 Not only is obesity associated with se-rious comorbidities, it is also very costly. Thedirect health care cost of obesity is estimated tobe $75 billion annually.4

Despite the growing need for therapeutic strat-egies to achieve and maintain weight loss, suchtreatments remain limited.5 Bariatric surgical pro-cedures, such as gastric bypass surgery, are amongthe few current treatments that produce perma-nent weight loss.6 Despite its efficacy, surgicaltreatment of obesity has generally been limited topatients suffering from morbid obesity, those witha body mass index of 40 kg/m2 or greater, as themajority of these patients would gain more benefit as compared with their overweight counterparts.

From Alameda Hospital, the University of California, Los Angeles David Geffen School of Medicine, and the University of California, Berkeley.Received for publication April 23, 2012; accepted August 23, 2012.Presented at the 29th Hawaii Plastic Surgery Symposium, in Honolulu, Hawaii, January 9 through 12, 2010.Copyright ©2013 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3182778649

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Surgical treatment in now considered the most effective treatment for the morbidly obesepopulation.7 Most evidence points to decreasedmorbidity and mortality as a result of the signifi-cant weight loss associated with this surgery.8,9

Abdominoplasty is a surgical treatment availableto a greater spectrum of patients looking to decreasethe size and improve the aesthetics of their midsec-tion, whether because of a large abdominal pannusresulting from massive weight loss, dermachalasis,and prominent stria following multiple pregnancies,or because of scarring and hernia formation pro-duced by previous operations.10 Whether or not long-term weight reduction is associated with ab-dominoplasty has been little investigated and re-mains controversial.11 Possible factors implicated with weight loss following abdominoplasty includetechnique, premorbid weight, motivation, postop-

erative diet and exercise, previous bariatric surgery,and size of pannus resected. The purpose of thepresent study was to determine whether or not ourpatient population was successful in obtaining a weight reduction after abdominoplasty, and if so, what factors were associated with maintaining long-term weight reduction.

PATIENTS AND METHODSBetween October of 2001 and September of

2007, 60 patients underwent abdominoplasty per-formed by one surgeon (R.E.M.B.). A retrospec-

tive chart review and an in-depth patient follow-upinterview were conducted on these patients to ob-tain the following information: age, height, andsex of the patient; previous bariatric surgery; weight of the resected pannus; weight before theabdominoplasty and chronologically after surgery;satiety following surgery; satisfaction with abdomi-noplasty results; and postsurgery lifestyle, includ-ing diet, exercise regimen, and personal beliefs asto the cause of weight loss.

Of the original 60 patients, 39 could not becontacted for the follow-up interview and thus

were excluded from the results of this study. Anadditional patient was excluded from analysis be-cause of pregnancy in the postoperative year. Of the remaining 20 patients—all women—five hadpreviously undergone bariatric surgery but wereincluded in our results. The 20 patients rangedin age from 26 to 61 years, with a meanϮ SD of 45.1Ϯ 10.4 years.

The surgical technique used involved pannusresection in the jackknife, 90-degree-flexed posi-tion, which was preceded by a tight two-layer per-manent suture rectus anterior fascia plication

from the xiphoid to the pubic bone. All patients

received thromboembolic deterrent stockings be-fore surgery, and pneumatic compression wasstarted as soon as the patients arrived in the op-erating room and continued until discharge, 1 day after surgery. No prophylactic anticoagulation wasgiven. All patients kept thromboembolic deterrent stockings and a firm abdominal binder on at alltimes for 4 to 6 weeks after surgery and were placedon rented surgical beds with knee flexion at 25 de-grees or more in a jackknife sitting position at home. We encouraged our patients to eat more healthfully and exercise for at least 45 minutes 3 times per weekstarting 6 weeks after surgery.

In our analysis, all calculations of changes inpatient body mass index after abdominoplasty used the patient’s postoperative body mass index,calculated using the preoperative weight minusthe weight of resected pannus, as the baseline

body mass index. Weight loss lasting less than 1 year was considered short-term weight loss, whereas weight loss enduring more than 1 year wasconsidered long-term weight loss.

Statistical AnalysisThere are a variety of statistical methods used

in the analysis of the patients who underwent ab-dominoplasty. All statistical analyses were per-formed in MATLAB 7.5 R2007b (The MathWorks,Inc., Natick, Mass.) with selected figures in R (R

Foundation for Statistical Computing, Vienna, Austria). For the comparison between preopera-tive body mass index for those with and without long-term weight loss, an unpaired two-sample t test was used with a significance level of 0.05. Where appropriate, one-way analysis of variance was used. All results are given using mean Ϯ SEM.To aid in the determination of a clinical threshold,receiver operating characteristic curve analysis wasused to evaluate the performance of preoperativebody mass index to predict long-term weight lossand to determine a threshold for the size of thepannus. All correlations were performed usingPearson correlation and, finally, the Fisher’s exact test was used to statistically compare the subjectiveresponses of the patients.

RESULTSFollow-up interviews and charted information

were obtained on 20 patients, with an averagefollow-up time of 29 months (range, 15 to 54months). Preoperative mean Ϯ SEM body massindex was 27.645 Ϯ 1.0 kg/m2, and the weight of the resected pannus was 5.215Ϯ 0.7 lb. Of the 20

patients, 14 (70 percent) had sustained weight loss

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beyond postoperative weight (preoperative minuspannus) at 1 year. The remaining six (30 percent)patients experienced some degree of weight lossfollowing surgery; however, they exceeded theirpostoperative body mass index at the 1-year follow-up. Of the patients with long-term weight loss, thepreoperative body mass index was 29.7 Ϯ 0.9kg/m2 versus 22.9 Ϯ 1.2 kg/m2. Based on receiveroperating characteristic curve analysis, the highsensitivity and specificity cutoff point for long-term weight loss is at a preoperative body massindex of 24.5 kg/m2, with a sensitivity of 92.9 per-cent, a specificity of 83.3 percent, and an accuracy of 90 percent. Based on this threshold, patients with a preoperative body mass index greater thanor equal to 24.5 kg/m2 have a significantly ( p ϭ0.014) greater decrease in body mass index beyond pannus weight at 1 year compared with those

at or below this threshold (an average change inbody mass index at 1 year of Ϫ4.5 Ϯ1.4 percent versus 2.0 Ϯ 1.7 percent). Of patients with a body mass index above 24.5 kg/m2, 92.8 percent (n ϭ13) had long-term weight loss at 1 year as com-pared with 16.7 percent (n ϭ 1) of patients below this threshold.

The trends of the short- and long-term weight loss groups are shown for preoperative body massindex, postoperative body mass index, minimumbody mass index, and 1-year body mass index inFigure 1. The short- and long-term data are sig-

nificantly different for all four time points ( p Ͻ0.001, p Ͻ 0.001, p Ͻ 0.01, and p ϭ 0.024, respec-tively). Table 1 shows postoperative body massindex, maximum change in body mass index, and

time to maximum weight loss for the short- andlong-term weight loss groups. The long-term weight loss group had a significantly higher pre-operative and postoperative body mass indexand greater maximum change in body mass in-dex when compared with the short-term weight loss group (Fig. 2). The time to maximum weight loss did not reach significance.

When patients were asked for the most impor-tant factors contributing to their weight loss, 75.0percent (n ϭ 15) reported an increased feeling of satiety, either with eating or generally throughout the day. When asked what led to the weight loss,only one (5 percent) attributed it to diet alone;eight (40 percent) to satiety alone; five (25 per-cent) to a combination of diet, exercise, and/orsatiety; three (15 percent) to their previous gastricbypass; and the remaining three (15 percent) toother reasons. Of those experiencing satiety, 60percent (n ϭ 9) retained that sensation at 1 year, whereas in the other 40 percent (n ϭ 6) it lastedan average of 3.9 months. For the long-term weight loss group specifically, 85.7 percent (n ϭ12) reported a change in satiety (seven had early satiety with eating only and five had a generalfeeling of fullness at all times). For the short-term weight loss group, 50.0 percent (n ϭ 3) reportedan increase in satiety, with a majority of thosehaving a general sense of satiety throughout the

day. A complete description for the degree of sa-tiety is shown in Table 2. Using the Fisher’s exact test, no significant relationship was found betweenthe short- and long-term weight loss groups ( p ϭ0.17) with respect to satiety.

We also wondered whether the size/weight of the pannus might be directly associated with long-term weight reduction. Using receiver operatingcharacteristic curve analysis, the optimal thresh-old for differentiating the short- and long-term weight loss groups produced a pannus size of 4.5lb, with a respective sensitivity and specificity of

85.7 and 100 percent. Based on this threshold,eight patients had an excised pannus under 4.5 lb,and the remaining 12 patients had a pannusgreater than 4.5 lb. The preoperative body massindex was significantly higher in the larger pannusgroup ( p Ͻ 0.001), which is reinforced by thesignificant positive correlation between pannussize and preoperative body mass index ( p Ͻ0.001). Both the maximum change in body massindex and the change in body mass index at 1 year were not significantly different between the twopannus groups. The complete data are listed in

Table 3.

Fig. 1. Average patient body mass index (BMI ) preoperatively

andpostoperatively, minimum bodymass index, and bodymass

index at 1 year for the long- and short-term weight loss groups.

SEM bars are shown at each of the measurement times.

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Finally, Table 4 shows the relationship in pannussize, maximum change in body mass index, changein body mass index at 1 year, time to maximumchange, and number of patients with long-term weight loss for three standard body mass index cat-egories (normal to underweight, Ͻ25 kg/m2; overweight, 25 to 30 kg/m2; and obese, Ͼ30 kg/m2).Using one-way analysis of variance, the pannus weights between the normal weight group (body mass index Ͻ25) and the obese group (body massindexϾ30) are significantly different. The relation-ship in maximum change in body mass index and1-year change in body mass index among thesegroups is shown in Figure 3.Fig. 2. Violin plots for preoperative body mass index (BMI ) in

short- and long-term weight loss groups.

Table 1. Change from Postoperative Body Mass Index with Respect to Short- and Long-Term WeightLoss Groups*

No. of Patients (%)

PostoperativeBMI (kg/m2)

Maximum Changein BMI (%)

Time of Maximum Weight Loss (wk)

Change in BMIat 1 Yr (%)

Short-term weight loss 6 (30%) 22.5 Ϯ 1.1 Ϫ3.6 Ϯ 0.8 7.1 Ϯ 1.3 3.2 Ϯ 1.3Long-term weight loss 14 (70%) 28.6 Ϯ 0.9 Ϫ8.8 Ϯ 1.4 13.4 Ϯ 2.0 Ϫ5.0 Ϯ 1.2

p N/A Ͻ0.001 0.032 0.093 0.001BMI, body mass index; N/A, not applicable.*SEM and significance are provided.

Table 2. Satiety in Short- and Long-Term Weight Loss Groups

No. of Patients

No Change in Appetite (%)

Sense of Satiety Only with Eating (%)

Sense of Satiety Throughout the Day (%)

Short-term weight loss 6 3 (50.0) 1 (16.6) 2 (33.3)Long-term weight loss 14 2 (14.3) 7 (50.0) 5 (35.7) All patients 20 5 (25.0) 8 (40.0) 7 (35.0)

Table 3. Changes in Body Mass Index as a Function of Resected Pannus Weight*

Weight of Pannus

No. of Patients (%)

PreoperativeBMI (kg/m2)

Maximum Changein BMI (%)

Change in BMIat 1 Yr (%)

No. with Long-Term Weight Loss

Յ4.5 lb 8 (40) 23.4 Ϯ 0.9 Ϫ4.3 Ϯ 0.8 1.1 Ϯ 1.7 2Ͼ4.5 lb 12 (60) 30.5 Ϯ 0.9 Ϫ9.2 Ϯ 1.6 Ϫ4.9 Ϯ 1.4 12 p N/A Ͻ0.001 0.029 0.01 N/A

BMI, body mass index; N/A, not applicable.*SEM and significance are provided.

Table 4. Statistics with Respect to Patient Body Mass Index Categories: Normal Weight, Overweight,and Obese*

PreoperativeBMI (kg/m2)

No. of Patients (%)

Pannus Weight (lb)

MaximumChange in BMI (%)

1-Yr Changein BMI (%)

Time to ReachMaximum Weight

Loss (wk)

No. of Patients with Weight

Loss at 1 Yr (%)

Յ25 7 (35) 3.2 Ϯ 1.0 Ϫ4.7 Ϯ 1.0 0.7 Ϯ 1.9 12.2 Ϯ 3.6 2 (28.6)25–30 7 (35) 4.7 Ϯ 0.6 Ϫ8.4 Ϯ 1.8 Ϫ4.7 Ϯ 2.4 13.1 Ϯ 2.8 6 (85.7)Ն30 6 (30) 8.1 Ϯ 1.4 Ϫ8.8 Ϯ 2.8 Ϫ3.7 Ϯ 1.8 8.8 Ϯ 0.9 6 (100) p N/A 0.01 0.28 0.17 0.59 N/A

BMI, body mass index; N/A, not applicable.*Statistics with respect to patient normal weight, overweight, and obese BMI categories. SEM and analysis of variance significance are

provided.


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DISCUSSIONThe current retrospective study found that all

patients undergoing abdominoplasty had somedegree of weight loss beyond that of their resectedpannus. Of these patients, 70 percent (n ϭ 14)maintained weight loss at 1 year. The most com-monly reported factor attributed to this weight loss is a sense of satiety, found in 75 percent (n ϭ

15) of patients, either as general satiety through-out the day or early satiety with eating. The majority [n ϭ 9 (60 percent)] of patients experienc-ing satiety maintained that sensation at 1 year, whereas in others it lasted an average of 15.7Ϯ 2.8 weeks. It is possible that a loss or decrease in satiety contributes to weight regain, as all patients re-gained some weight after reaching their nadiraround this same time (11.6 Ϯ 1.7 weeks). Al-though there was a trend toward patients withsatiety achieving more long-term weight loss, thisdid not reach statistical significance ( p ϭ 0.17).

When trying to determine what other factorsare associated with long-term weight loss, wefound that patient preoperative body mass index was significantly correlated, with those weighinggreater than or equal to 24.5 kg/m2 achievinglong-term weight loss with a sensitivity and speci-ficity of 92.9 and 83.3 percent, respectively. Of patients with a preoperative body mass indexgreater than or equal to 24.5 kg/m2, 92.8 percent (n ϭ 13) maintained long-term weight loss at 1 year as compared with 16.6 percent (n ϭ 1) of those below this threshold. At 1 year, patients be-

low this threshold gained an average of 2.0Ϯ

1.7

percent of their postoperative body weight as com-pared with a loss of 4.5Ϯ 1.5 percent in those withbody mass indexes above 24.5 kg/m2 ( p ϭ 0.014).This tells us that overweight and obese patientstend to have more long-term weight reductionbenefit from abdominoplasty than their normal- weight counterparts. Although this may be be-cause normal weight patients have less body fat to

lose, it is possible that a change in neuroendocrinefactors as discussed below affects overweight andobese patients to a greater extent.

Another factor significantly correlated withlong-term weight loss is the weight of the resectedpannus. Patients with pannus resections weighinggreater than 4.5 lb had significantly greaterchanges in body mass index at minimum and1-year time points ( p ϭ 0.029 and p ϭ 0.01, re-spectively) compared with those with smaller re-sections. Although the weight of the resected pan-nus is logically dependent on patient body mass

index and the correlation with long-term weight loss may simply be a product of body mass indexeffect, it must also be considered that the greaterthe amount of fat cells removed, the greater theimpact on the neuroendocrine milieu regulatingsatiety and weight balance, as discussed below. Inparticular, the possibility that removing fat cellsthat produce leptin may reduce leptin resistancehas been described in the obese patient.12

We hypothesize that the increased satiety seenin our patients and subsequent weight loss is re-lated to changes in the neuroendocrine system.

This is supported by the latest studies on appetite that

Fig. 3. Percentage change in body mass index (BMI ) at minimum body mass index and

1-year time points for patients with a body mass index less than 24.5 kg/m 2 and greater

than or equal to 24.5 kg/m2. The black bars represent the maximum percentage change

in body mass index over the1-year follow-up period, whereas the lighter bars representsthe change from the postoperative body mass index at 1 year. SEM bars are shown.


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have found that food intake is regulated by theaction of gastrointestinal peptide hormones andleptins, hormones secreted from adipose tissue,on the central nervous system. These hormonesact as satiety signals in the vagal-brainstem-hypo-thalamic pathway.13 In the hypothalamus, gut hor-mones and leptins act by stimulating/inhibitingneurons in the arcuate nucleus of the hypothala-mus. In turn, this control center responds by ex-pressing peptides that either stimulate or inhibit food intake.13–16 Afferent signals from the vagusnerve convey information about the mechanicaland chemical stimulation of the gastrointestinaltract by ingested food to the brainstem. This fur-ther elicits reflexes that control gastrointestinalfunctions and sends signals to the hypothalamusto inhibit food intake.16,17 The vagus nerve con-tains mechanoreceptors that are sensitive to stom-

ach and intestinal volume and luminal pressureand receptors for a number of gut hormones. Thisthen conveys information about the ingestedfood.16,18–21 Studies have shown that vagotomy abolishes the appetite-modifying actions of thesegut hormones.20,22–24

Many gastrointestinal peptide hormones andleptins have been discovered. They are known toinhibit/stimulate food intake by acting at the vagus nerve and/or the arcuate nucleus. Forexample, leptin, which is released from adiposetissue, and insulin, which is secreted by the pan-

creas, both function within the hypothalamus toinhibit food intake.15,25,26 Cholecystokinin, incontrast, is secreted by the I cells of the smallintestine and acts mainly through the vagus nerveto inhibit feeding by modifying gastrointestinaltract functions.15,20,27,28 Peptide YY, oxyntomodu-lin, and glucagon-like peptide-1 are all secretedfrom L cells in the intestines. They act on both thehypothalamus and the vagus nerve to inhibit foodintake.15,28,29,30 Pancreatic peptide, released fromthe pancreas; glucose-dependent insulinotropicpolypeptide, secreted from the stomach, duode-

num, and jejunum; adiponectin, produced by ad-ipose tissue; and amylin, from the pancreas, areother satiety-promoting gut hormones.13,15,16 Sofar, ghrelin, which is produced in the stomach, isthe only known circulating appetite stimulant. It functions at the hypothalamic level.13,15,16

This is a pilot study, and with future studies, we would propose measuring levels of these gastro-intestinal peptide hormones before our patientsundergo abdominoplasty and then at incrementaltimes after surgery. By comparing hormone levelsbefore and after abdominoplasty, we will be able

to determine whether there is any significant

change in gastrointestinal peptide hormone orleptin expression. This will elucidate the satiety signals that are responsible for the loss of appetitefound in our patients. Further studies will clarify the mechanisms of appetite regulation and may lead to the creation of an injectable appetite sup-pressant drug. With the increasing global preva-lence of obesity and its ensuing physiologic, psy-chological, and economic implications, the needto understand appetite control is imperative.

Rex E. Moulton-Barrett, M.D.

2070 Clinton Avenue Alameda, Calif. 95401

[email protected]

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weight reduction following abdominoplasty a.36

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