The number of patients undergoing gastric bypass surgery has risen by over 600% in the past decade: nearly 150,000 operations were performed in 2004. The number of patients undergoing body contouring plastic surgery has risen by over 800% in the past seven years: over 300,000 tummy tucks, upper arm, breast, buttock, thigh, and lower body lifts lifts were performed in 2004. Two thirds of Americans over the age of 20 are overweight; 5-10million are morbidly obese (BMI over 40).*
*American Society for Bariatric Surgery; American Society for Aesthetic Plastic Surgery statistics
With all of this loose skin, it is little wonder why patients are seeking plastic surgeons that are not only appropriately board-certified and fully trained in the latest body-lifting and skin-tightening techniques, but those that have their own surgical facilities and the significant cost-savings of outpatient expertise.
“Massive weight-loss patients, regardless of whether they have gastric bypass or lose their weight by other means, have invested a tremendous amount of time, effort, energy, and finances to reach the point where they now have loose, stretched skin that will not respond to anything but surgical removal. No amount of sit-ups, crunches, or leg lifts can rebuild the loss of elasticity and actual collagen content in skin that once contained another whole human in weight,” says Dr. Tholen, president and senior partner of Minneapolis Plastic Surgery, Ltd., past-president of the Minnesota Society of Plastic Surgeons, and immediate past-president of the Midwestern Association of Plastic Surgeons. “In fact,” he adds “Dr. Gervais and I see patients who have exercised, dieted, and eaten miniscule portions so well they have become extremely frustrated by the fact that their bodies have shrunk and their muscles toned, but their skin did not. A few feel betrayed by their bodies: they’ve worked so hard yet still look anything but normal—they have gone from the poor self-esteem, public scorn, and disability of obesity, to feeling like bodybuilders in Shar-pei skin.”
FINDING THE RIGHT SURGEON
Most board-certified plastic surgeons perform cosmetic breast lifts and tummy tucks, many perform thigh lifts and upper arm lifts, and a lesser number perform buttock or full circumferential lower body lifts. Prospective patients should always check that their plastic surgeon or cosmetic surgeon is certified by the American Board of Plastic Surgery, which is one of 24 Boards administered by the American Board of Medical Specialties (ABMS).
As massive weight-loss patients reach their body weight goals, they contemplate the prospect of multiple additional surgeries to remove and tighten their loose skin. One of the greatest areas of concern is the abdomen, where the “apron” or pannus of loose skin folds over the pubic area. Often this loose skin extends around to the lateral thighs, hips, and buttocks. A “standard” or even “extended” abdominoplasty (tummy tuck) does not do the necessary job—removal of an entire circumferential band of loose skin termed “circumferential belt-lift plus abdominoplasty.” Other surgeons have described this operation as “torsoplasty,” “lower body lift,” and have even subclassified them into Type I and II lifts. A full circumferential beltlift is an operation that not every plastic surgeon performs, and even fewer have extensive experience with, causing most doctors to describe these operations as lengthy, difficult, expensive, and almost always requiring inpatient overnight stays in the hospital.
WHY IS A BELTLIFT SO DIFFICULT?
Most full circumferential beltlift (lower body lift) operations require a surgical team experienced in total body prepping (the surgical iodine scrub of the skin done in the operating room just prior to surgery), at least three position changes of the anesthetized patient on the operating table to reach all the way around the body with the incisions and sutures, and the technical surgical and anesthesia expertise to do this all with safety and minimal blood loss. A review of the surgical literature reveals that most surgeons who perform this procedure require inpatient hospitalization, some utilize the assistance of a second plastic surgeon, and virtually all require 6—or up to 9 or more—hours in the operating room.
AND WHY IS IT SO EXPENSIVE?
This long an operation with traditional hospital anesthesia often results in prolonged time in the recovery room, as well as postoperative nausea and vomiting from some of the anesthetic agents, such as inhalation anesthesia, nitrous oxide, and intravenous morphine or other narcotic drugs. These medications, while providing safe and effective anesthesia, dilate the gut and middle ear, slow peristalsis in the intestinal tract and stomach, and accumulate in fatty tis sue (including the brain, where the individual neurons are shielded from short-circuit by fatty sheaths called myelin), causing dizziness, bloating, nausea, vomiting, and that nasty smell as your body exhales the gases stored in those tis sues. Anti-nausea medication works for some—but for as many as one fourth of patients it is instant overnight stay. The cost of this type of hospital beltlift and inpatient care can be 20, 25, or even 30 thousand dollars. Add a second day and the cost goes up again.
IS THERE AN ALTERNATIVE (THAT’S STILL SAFE)?
Hospitals utilize this type of inhalation anesthesia because it is safe, but also because it is very inexpensive. Cost, particularly for large hospitals or networks, is a major factor in anesthetic drug choice. ‘Standard’ anesthetics purchased in bulk are inexpensive . . . and the cost for additional hours in the recovery room fighting nausea and vomiting, or admission for overnight stay, is “someone else’s” cost. Some studies show postoperative nausea and vomiting rates with this type of anesthesia as high as 7-28%. When an elective cosmetic patient is the one staying overnight, or a day or two, the patient pays the additional cost, not an insurance company.
Minneapolis Plastic Surgery has offered anesthesia services for major cosmetic outpatient surgical procedures in our three accredited operating rooms for over 25 years. Since 1991, MPS has had full general anesthesia capability, but with one significant difference from the hospital routine: we have utilized intravenous general anesthesia, not just for induction, but for the entire operation. We use little or no inhalation anesthetic agent, and the same goes for nitrous oxide—they just contribute to too much nausea. MPS also does some innovative things with pain and inflammation management, we pretreat for nausea avoidance, and right before wake-up we routinely inject long-acting local anesthetics into areas of muscle spasm or incisional discomfort—in short, we do battle with all the causes of nausea and vomiting, even though this anesthetic regimen is much more costly.
With over 15 years of this type of high-tech, higher-cost anesthesia, we have reduced our nausea rate to just fewer than 2%, and that includes six and seven-hour operations on all parts of the body. Of course, Dr. Gervais and Dr. Tholen have the advantage of performing elective surgical procedures on motivated patients that are healthy and prescreened by their own physician prior to having cosmetic surgery. Minneapolis Plastic Surgery’s first complete beltlift plus abdominoplasty, along with medial thighlift and some liposuction, was performed in 1997.
PROPERLY DONE, OUTPATIENT IS BEST
Since that time, Dr. Richard Tholen and his partner Dr. Doug Gervais have performed over 150 full circumferential beltlift plus abdominoplasty operations as outpatient procedures in their office operating facility. Each plastic surgeon has his own full surgical and anesthetic team, and each operates daily. In fact, two outpatient beltlift procedures have been performed at the same time on several occasions at MPS. A limited number of plastic surgeons have this degree of experience and expertise with this type of operation; but to our knowledge, nobody else is doing this specific operation consistently as an outpatient procedure as MPS has been doing.
In a presentation to the Midwestern Association of Plastic Surgeons in April, 2005, and at an International Plastic Surgery Conference in January, 2007, Dr. Tholen taught the specifics of the requirements for safe outpatient circumferential beltlift surgery. “Anesthesia is the first of several essentials. It has to be done in a way that avoids any potentially nausea-causing medications, and the other details of how we reduce pain, muscle spasm, inflammation, and incisional discomfort were discussed.”
“Dr. Gervais and I were happy to report no major complications, and I believe that this procedure being done as an outpatient may actually reduce some complications, since our patients are required to be up walking, going to the restroom, and returning for office rechecks more quickly than hospital patients. This reduces swelling and bruising, keeps blood moving in the legs to reduce the risk of blood clots, and helps to get their intestinal tract working faster than the bedridden patient. Our average operating time with one surgeon (and RN first assistant) was 5.5 hours, including additional cosmetic procedures in almost half of our patients. The most common additional procedures were liposuction, gynecomastia surgery (male breast reduction), ventral hernia repair, and breast augmentation. We removed an average of 8.2 pounds of skin and fat per patient (up to 23.7 pounds in one patient), and an additional 2 pounds via liposuction. Three patients had postoperative nausea (just over 2%), and there were 17% minor complications, all of which resolved with conservative outpatient care. Patient satisfaction was very high, especially considering the savings of thousands compared to similar operation performed as hospital cases.”
Both Dr.Gervais and Dr.Tholen have had a decade of experience with outpatient surgery for massive weight loss patients requesting circumferential beltlift, whether their loose skin is a result of gastric bypass, gastric banding, or any other type of weight-loss. They both also perform breast lift, arm lift (brachioplasty), facelift, thighlift, and other skin-tightening operations for their patients, often combining several procedures together to reduce time off work, risks, and costs.
For more information, or to schedule a complimentary consultation with our plastic surgeons, please call: 763-545-0443
