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Weight Reduction following Abdominoplasty: A Retrospective Case Review Pilot Study

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					COSMETIC

Weight Reduction following Abdominoplasty:
A Retrospective Case Review Pilot Study
    Jennifer C. Fuller, M.A.
                                      Background: The question of whether or not abdominoplasty is associated with
 Catherine N. Nguyen, B.A.            permanent weight reduction remains controversial. In coalition, should ab-
 Rex E. Moulton-Barrett, M.D.         dominoplasty be used as an adjunct for weight reduction in the overweight/
         Alameda, Los Angeles, and    obese patient?
                   San Jose, Calif.   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 1.7
                                      weeks after surgery. Weight loss is attributed to an increase in satiety by 75
                                      percent (n 15) of patients. Preoperative body mass index greater than or equal
                                      to 24.5 kg/m2 can be used to predict long-term weight loss with a sensitivity and
                                      specificity of 92.9 percent and 83.3 percent, respectively. Patients above this
                                      threshold achieved significantly more weight loss ( 4.5 1.4 percent body mass
                                      index) at 1 year compared with their lower body mass index counterparts (p
                                      0.014), as did those with pannus resections weighing greater than 4.5 lb (p
                                      0.01).
                                      Conclusions: Abdominoplasty performed on patients with a body mass index
                                      greater 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.




T
      he prevalence of obesity, defined by the Na-              as it increases the risk of many diseases and health
      tional Institutes of Health as a body mass                conditions, including but not limited to sleep
      index of 30 kg/m2or greater,1 has more than               apnea, diabetes mellitus, hypertension, osteoar-
doubled in the United States since 1980.2 Accord-               thritis, dyslipidemia, certain types of cancers,
ing to a recent National Health and Nutrition                   gallbladder disease, stroke, and coronary heart
Examination Survey, a staggering 33.3 percent of                disease.3 Not only is obesity associated with se-
adult men and 35.3 percent of adult women in the                rious comorbidities, it is also very costly. The
United States are currently considered obese.2                  direct health care cost of obesity is estimated to
Obesity is caused by a long-term positive energy                be $75 billion annually.4
balance where energy intake is greater than its                      Despite the growing need for therapeutic strat-
expenditure. With portion sizes and consumption                 egies to achieve and maintain weight loss, such
of high-calorie foods continuing to increase and                treatments remain limited.5 Bariatric surgical pro-
physical activity on the decline, it is not surprising          cedures, such as gastric bypass surgery, are among
that the rate of obesity continues to climb. The                the few current treatments that produce perma-
obesity epidemic presents a major health concern,               nent weight loss.6 Despite its efficacy, surgical
                                                                treatment of obesity has generally been limited to
                                                                patients suffering from morbid obesity, those with
 From Alameda Hospital, the University of California, Los       a body mass index of 40 kg/m2 or greater, as the
 Angeles David Geffen School of Medicine, and the University    majority of these patients would gain more benefit
 of California, Berkeley.                                       as compared with their overweight counterparts.
 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.                    Disclosure: The authors have no financial interest
 Copyright ©2013 by the American Society of Plastic Surgeons      to declare in relation to the content of this article.
 DOI: 10.1097/PRS.0b013e3182778649

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Volume 131, Number 2 • Weight Reduction after Abdominoplasty

Surgical treatment in now considered the most            received thromboembolic deterrent stockings be-
effective treatment for the morbidly obese               fore surgery, and pneumatic compression was
population.7 Most evidence points to decreased           started as soon as the patients arrived in the op-
morbidity and mortality as a result of the signifi-      erating room and continued until discharge, 1 day
cant weight loss associated with this surgery.8,9        after surgery. No prophylactic anticoagulation was
     Abdominoplasty is a surgical treatment available    given. All patients kept thromboembolic deterrent
to a greater spectrum of patients looking to decrease    stockings and a firm abdominal binder on at all
the size and improve the aesthetics of their midsec-     times for 4 to 6 weeks after surgery and were placed
tion, whether because of a large abdominal pannus        on rented surgical beds with knee flexion at 25 de-
resulting from massive weight loss, dermachalasis,       grees or more in a jackknife sitting position at home.
and prominent stria following multiple pregnancies,      We encouraged our patients to eat more healthfully
or because of scarring and hernia formation pro-         and exercise for at least 45 minutes 3 times per week
duced by previous operations.10 Whether or not           starting 6 weeks after surgery.
long-term weight reduction is associated with ab-             In our analysis, all calculations of changes in
dominoplasty has been little investigated and re-        patient body mass index after abdominoplasty
mains controversial.11 Possible factors implicated       used the patient’s postoperative body mass index,
with weight loss following abdominoplasty include        calculated using the preoperative weight minus
technique, premorbid weight, motivation, postop-         the weight of resected pannus, as the baseline
erative diet and exercise, previous bariatric surgery,   body mass index. Weight loss lasting less than 1
and size of pannus resected. The purpose of the          year was considered short-term weight loss,
present study was to determine whether or not our        whereas weight loss enduring more than 1 year was
patient population was successful in obtaining a         considered long-term weight loss.
weight reduction after abdominoplasty, and if so,
what factors were associated with maintaining long-      Statistical Analysis
term weight reduction.
                                                              There are a variety of statistical methods used
         PATIENTS AND METHODS                            in the analysis of the patients who underwent ab-
     Between October of 2001 and September of            dominoplasty. All statistical analyses were per-
2007, 60 patients underwent abdominoplasty per-          formed in MATLAB 7.5 R2007b (The MathWorks,
formed by one surgeon (R.E.M.B.). A retrospec-           Inc., Natick, Mass.) with selected figures in R (R
tive chart review and an in-depth patient follow-up      Foundation for Statistical Computing, Vienna,
interview were conducted on these patients to ob-        Austria). For the comparison between preopera-
tain the following information: age, height, and         tive body mass index for those with and without
sex of the patient; previous bariatric surgery;          long-term weight loss, an unpaired two-sample t
weight of the resected pannus; weight before the         test was used with a significance level of 0.05.
abdominoplasty and chronologically after surgery;        Where appropriate, one-way analysis of variance
satiety following surgery; satisfaction with abdomi-     was used. All results are given using mean SEM.
noplasty results; and postsurgery lifestyle, includ-     To aid in the determination of a clinical threshold,
ing diet, exercise regimen, and personal beliefs as      receiver operating characteristic curve analysis was
to the cause of weight loss.                             used to evaluate the performance of preoperative
     Of the original 60 patients, 39 could not be        body mass index to predict long-term weight loss
contacted for the follow-up interview and thus           and to determine a threshold for the size of the
were excluded from the results of this study. An         pannus. All correlations were performed using
additional patient was excluded from analysis be-        Pearson correlation and, finally, the Fisher’s exact
cause of pregnancy in the postoperative year. Of         test was used to statistically compare the subjective
the remaining 20 patients—all women—five had             responses of the patients.
previously undergone bariatric surgery but were
included in our results. The 20 patients ranged                              RESULTS
in age from 26 to 61 years, with a mean SD of 45.1           Follow-up interviews and charted information
   10.4 years.                                           were obtained on 20 patients, with an average
     The surgical technique used involved pannus         follow-up time of 29 months (range, 15 to 54
resection in the jackknife, 90-degree-flexed posi-       months). Preoperative mean        SEM body mass
tion, which was preceded by a tight two-layer per-       index was 27.645 1.0 kg/m2, and the weight of
manent suture rectus anterior fascia plication           the resected pannus was 5.215 0.7 lb. Of the 20
from the xiphoid to the pubic bone. All patients         patients, 14 (70 percent) had sustained weight loss

                                                                                                         239e
                                                             Plastic and Reconstructive Surgery • February 2013

beyond postoperative weight (preoperative minus                    time to maximum weight loss for the short- and
pannus) at 1 year. The remaining six (30 percent)                  long-term weight loss groups. The long-term
patients experienced some degree of weight loss                    weight loss group had a significantly higher pre-
following surgery; however, they exceeded their                    operative and postoperative body mass index
postoperative body mass index at the 1-year follow-                and greater maximum change in body mass in-
up. Of the patients with long-term weight loss, the                dex when compared with the short-term weight
preoperative body mass index was 29.7            0.9               loss group (Fig. 2). The time to maximum
kg/m2 versus 22.9 1.2 kg/m2. Based on receiver                     weight loss did not reach significance.
operating characteristic curve analysis, the high                       When patients were asked for the most impor-
sensitivity and specificity cutoff point for long-                 tant factors contributing to their weight loss, 75.0
term weight loss is at a preoperative body mass                    percent (n 15) reported an increased feeling of
index of 24.5 kg/m2, with a sensitivity of 92.9 per-               satiety, either with eating or generally throughout
cent, a specificity of 83.3 percent, and an accuracy               the day. When asked what led to the weight loss,
of 90 percent. Based on this threshold, patients                   only one (5 percent) attributed it to diet alone;
with a preoperative body mass index greater than                   eight (40 percent) to satiety alone; five (25 per-
or equal to 24.5 kg/m2 have a significantly (p                     cent) to a combination of diet, exercise, and/or
0.014) greater decrease in body mass index be-                     satiety; three (15 percent) to their previous gastric
yond pannus weight at 1 year compared with those                   bypass; and the remaining three (15 percent) to
at or below this threshold (an average change in                   other reasons. Of those experiencing satiety, 60
body mass index at 1 year of 4.5 1.4 percent                       percent (n 9) retained that sensation at 1 year,
versus 2.0 1.7 percent). Of patients with a body                   whereas in the other 40 percent (n 6) it lasted
mass index above 24.5 kg/m2, 92.8 percent (n                       an average of 3.9 months. For the long-term
13) had long-term weight loss at 1 year as com-                    weight loss group specifically, 85.7 percent (n
pared with 16.7 percent (n 1) of patients below                    12) reported a change in satiety (seven had early
this threshold.
                                                                   satiety with eating only and five had a general
    The trends of the short- and long-term weight
                                                                   feeling of fullness at all times). For the short-term
loss groups are shown for preoperative body mass
                                                                   weight loss group, 50.0 percent (n 3) reported
index, postoperative body mass index, minimum
                                                                   an increase in satiety, with a majority of those
body mass index, and 1-year body mass index in
Figure 1. The short- and long-term data are sig-                   having a general sense of satiety throughout the
nificantly different for all four time points (p                   day. A complete description for the degree of sa-
0.001, p 0.001, p 0.01, and p 0.024, respec-                       tiety is shown in Table 2. Using the Fisher’s exact
tively). Table 1 shows postoperative body mass                     test, no significant relationship was found between
index, maximum change in body mass index, and                      the short- and long-term weight loss groups (p
                                                                   0.17) 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 operating
                                                                   characteristic curve analysis, the optimal thresh-
                                                                   old for differentiating the short- and long-term
                                                                   weight loss groups produced a pannus size of 4.5
                                                                   lb, 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 pannus
                                                                   greater than 4.5 lb. The preoperative body mass
                                                                   index was significantly higher in the larger pannus
                                                                   group (p        0.001), which is reinforced by the
                                                                   significant positive correlation between pannus
                                                                   size and preoperative body mass index (p
                                                                   0.001). Both the maximum change in body mass
Fig. 1. Average patient body mass index (BMI) preoperatively       index and the change in body mass index at 1 year
and postoperatively, minimum body mass index, and body mass        were not significantly different between the two
index at 1 year for the long- and short-term weight loss groups.   pannus groups. The complete data are listed in
SEM bars are shown at each of the measurement times.               Table 3.

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Volume 131, Number 2 • Weight Reduction after Abdominoplasty

Table 1. Change from Postoperative Body Mass Index with Respect to Short- and Long-Term Weight
Loss Groups*
                                 No. of        Postoperative       Maximum Change            Time of Maximum        Change in BMI
                              Patients (%)     BMI (kg/m2)           in BMI (%)               Weight Loss (wk)       at 1 Yr (%)
Short-term weight loss          6 (30%)          22.5 1.1               3.6 0.8                   7.1 1.3                3.2 1.3
Long-term weight loss          14 (70%)          28.6 0.9               8.8 1.4                  13.4 2.0                5.0 1.2
p                                N/A                0.001                0.032                     0.093                  0.001
BMI, body mass index; N/A, not applicable.
*SEM and significance are provided.


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


Table 2. Satiety in Short- and Long-Term Weight Loss Groups
                                  No. of           No Change in              Sense of Satiety                  Sense of Satiety
                                  Patients         Appetite (%)            Only with Eating (%)            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           No. of               Preoperative        Maximum Change            Change in BMI           No. with Long-Term
Pannus            Patients (%)           BMI (kg/m2)           in BMI (%)               at 1 Yr (%)                Weight Loss
    4.5 lb           8 (40)               23.4 0.9                 4.3 0.8                   1.1 1.7                      2
    4.5 lb          12 (60)               30.5 0.9                 9.2 1.6                   4.9 1.4                     12
p                    N/A                     0.001                  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*
                                                                                              Time to Reach        No. of Patients
Preoperative        No. of          Pannus            Maximum              1-Yr Change       Maximum Weight          with Weight
BMI (kg/m2)      Patients (%)      Weight (lb)    Change in BMI (%)        in BMI (%)           Loss (wk)          Loss at 1 Yr (%)
  25                 7 (35)         3.2 1.0                4.7 1.0            0.7 1.9            12.2 3.6               2 (28.6)
25–30                7 (35)         4.7 0.6                8.4 1.8            4.7 2.4            13.1 2.8               6 (85.7)
  30                 6 (30)         8.1 1.4                8.8 2.8            3.7 1.8             8.8 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.


                                                                                                                               241e
                                                         Plastic and Reconstructive Surgery • February 2013




                  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/m2 and greater
                  than or equal to 24.5 kg/m2. The black bars represent the maximum percentage change
                  in body mass index over the 1-year follow-up period, whereas the lighter bars represents
                  the change from the postoperative body mass index at 1 year. SEM bars are shown.



                   DISCUSSION                                   percent of their postoperative body weight as com-
     The current retrospective study found that all             pared with a loss of 4.5 1.5 percent in those with
patients undergoing abdominoplasty had some                     body mass indexes above 24.5 kg/m2 (p 0.014).
degree of weight loss beyond that of their resected             This tells us that overweight and obese patients
pannus. Of these patients, 70 percent (n            14)         tend to have more long-term weight reduction
maintained weight loss at 1 year. The most com-                 benefit from abdominoplasty than their normal-
monly reported factor attributed to this weight                 weight counterparts. Although this may be be-
loss is a sense of satiety, found in 75 percent (n              cause normal weight patients have less body fat to
15) of patients, either as general satiety through-             lose, it is possible that a change in neuroendocrine
out the day or early satiety with eating. The ma-               factors as discussed below affects overweight and
jority [n 9 (60 percent)] of patients experienc-                obese patients to a greater extent.
ing satiety maintained that sensation at 1 year,                    Another factor significantly correlated with
whereas in others it lasted an average of 15.7 2.8              long-term weight loss is the weight of the resected
weeks. It is possible that a loss or decrease in satiety        pannus. Patients with pannus resections weighing
contributes to weight regain, as all patients re-               greater than 4.5 lb had significantly greater
gained some weight after reaching their nadir                   changes in body mass index at minimum and
around this same time (11.6            1.7 weeks). Al-          1-year time points (p         0.029 and p     0.01, re-
though there was a trend toward patients with                   spectively) compared with those with smaller re-
satiety achieving more long-term weight loss, this              sections. Although the weight of the resected pan-
did not reach statistical significance (p 0.17).                nus is logically dependent on patient body mass
     When trying to determine what other factors                index and the correlation with long-term weight
are associated with long-term weight loss, we                   loss may simply be a product of body mass index
found that patient preoperative body mass index                 effect, it must also be considered that the greater
was significantly correlated, with those weighing               the amount of fat cells removed, the greater the
greater than or equal to 24.5 kg/m2 achieving                   impact on the neuroendocrine milieu regulating
long-term weight loss with a sensitivity and speci-             satiety and weight balance, as discussed below. In
ficity of 92.9 and 83.3 percent, respectively. Of               particular, the possibility that removing fat cells
patients with a preoperative body mass index                    that produce leptin may reduce leptin resistance
greater than or equal to 24.5 kg/m2, 92.8 percent               has been described in the obese patient.12
(n      13) maintained long-term weight loss at 1                   We hypothesize that the increased satiety seen
year as compared with 16.6 percent (n             1) of         in our patients and subsequent weight loss is re-
those below this threshold. At 1 year, patients be-             lated to changes in the neuroendocrine system.
low this threshold gained an average of 2.0 1.7                 This is supported by the latest studies on appetite that

242e
Volume 131, Number 2 • Weight Reduction after Abdominoplasty

have found that food intake is regulated by the           change in gastrointestinal peptide hormone or
action of gastrointestinal peptide hormones and           leptin expression. This will elucidate the satiety
leptins, hormones secreted from adipose tissue,           signals that are responsible for the loss of appetite
on the central nervous system. These hormones             found in our patients. Further studies will clarify
act as satiety signals in the vagal-brainstem-hypo-       the mechanisms of appetite regulation and may
thalamic pathway.13 In the hypothalamus, gut hor-         lead to the creation of an injectable appetite sup-
mones and leptins act by stimulating/inhibiting           pressant drug. With the increasing global preva-
neurons in the arcuate nucleus of the hypothala-          lence of obesity and its ensuing physiologic, psy-
mus. In turn, this control center responds by ex-         chological, and economic implications, the need
pressing peptides that either stimulate or inhibit        to understand appetite control is imperative.
food intake.13–16 Afferent signals from the vagus
                                                                                             Rex E. Moulton-Barrett, M.D.
nerve convey information about the mechanical                                                       2070 Clinton Avenue
and chemical stimulation of the gastrointestinal                                                  Alameda, Calif. 95401
tract by ingested food to the brainstem. This fur-                                            rex@moulton-barrett.com
ther elicits reflexes that control gastrointestinal
functions and sends signals to the hypothalamus                                    REFERENCES
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    2005;1044:127–131.                                                     127:546–558.




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Description: Background: The question of whether or not abdominoplasty is associated with permanent weight reduction remains controversial. In coalition, should abdominoplasty 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 � 1.7 weeks after surgery. Weight loss is attributed to an increase in satiety by 75 percent (n = 15) of patients. Preoperative body mass index greater than or equal to 24.5 kg/m2 can be used to predict long-term weight loss with a sensitivity and specificity of 92.9 percent and 83.3 percent, respectively. Patients above this threshold achieved significantly more weight loss (−4.5 � 1.4 percent body mass index) at 1 year compared with their lower body mass index counterparts (p = 0.014), as did those with pannus resections weighing greater than 4.5 lb (p = 0.01). Conclusions: Abdominoplasty performed on patients with a body mass index greater 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. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.