Brachioplasty. Arm Contouring.

 

When examining art throughout time, artists have traditionally had difficulty obtaining correct proportions of the upper extremity and hand in drawings, paintings, and sculpture.

Michelangelo’s painting on the Sistine Chapel ceiling shows excellent proportion's of the depiction of God and Adam's hands. However, one can easily ascertain how obtaining these proportions can be quite difficult.

Nonetheless to the Plastic & Reconstructive surgeon, obtaining the correct proportion in an "arm tuck" or brachioplasty can be quite challenging as well. Crucial to obtaining an optimal result is to avoid any pinching or constriction along the contour of the arm. Even more challenging is to gradually transition this contour into the "armpit" or axillae. Often liposuction is used in conjunction with the brachioplasty to adequately taper the contour.

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Brachioplasty. Post-Bariatric Body Contouring.

Successful brachioplasty or "arm tuck" surgery requires careful attention to detail to yield a natural contour to the arm. That is, it is paramount that their is an even and gradual contour of the arm from the forearm toward the axillae or "arm pit" often with modification of the lateral chest wall as shown in the above photograph.

Inadvertent over-resection of the skin and fat in the arm can lead to an abnormal pinched appearance. Successful brachioplasty surgery requires compliance on behalf of the patient to wear a compression garment or ace bandage on the arm for at least two weeks.

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Mastopexy. Post-Bariatric Body Contouring Surgery.

Mastopexy or "breast lift" surgery can be very rewarding for the patient and surgeon. Patients who loose greater than 100 lbs of weight with either lap band or gastric bypass procedures lose a significant amount of breast volume. This typically gives the breast a sagging or "ptotic" appearance. In addition, the position and volume of the breasts can interfere with physical activity or exercise.

The goal of breast lift surgery or mastopexy is to place the breast in a more youthful position on the chest wall. No only does this allow the breasts to appear more youthful, but also allows the torso to be elongated to give the body a better proportion-even more so if an abdominoplasty has been performed.

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Post Bariatric Body Contouring

Post-Bariatric Body Contouring Surgery is very rewarding to both the patient and Plastic & Reconstructive Surgeon.

Many patients ask me, Dr. D. what is bariatric surgery?

Bariatric surgery, or weight loss surgery, are procedures performed on people who are dangerously obese, for the purpose of losing weight and improving their overall health. Weight loss is achieved by reducing the size of the stomach, through removal of a portion of the stomach, or by resecting and re-routing the small intestines to a small stomach pouch. These procedures are called gastric banding, sleeve gastrectomy, or gastric bypass surgery, respectively. Not only can these surgeries produce significant long-term loss of weight, but also improve diabetes, lower blood pressure, improve cardiovascular risk factors, and reduce mortality.

Many patients then ask me, Dr. D. can bariatric surgery be covered or partially covered by my insurance?

Generally insurance will assist in covering these procedures for obese people with a BMI over 40 or people with a BMI of over 35 with coexisting medical conditions. Finally, patients will ask me, Dr. D. can the post-bariatric body contouring procedures be covered or partially covered by my insurance?
Patients who have bariatric procedures loose over 100 lbs of weight and are left with excess skin that they find impossible to loose. Occasionally, the abdominal skin that overhangs the pubis can cause rashes in the area between the skin. Typically, if patients have these rashes and they are not relieved by prescription medications or other conservative measures to treat them for over six months, then insurance will cover or partially cover a panniculectomy. A panniculectomy is the removal of the overhanging skin or pannus. Other post-bariatric procedures may be covered or partially covered by health insurance or patients may pay for these procedures out-of-pocket. .

I am frequently asked, Dr. Dickinson-What can I do nutritionally to prepare for surgery?

Post-bariatric body contouring procedures are significant surgeries that require a lot of energy expenditure for the body to heal. I typically tell patients to eat one to two grams of protein per kilogram of body weight 4 weeks prior to and 4 weeks after surgery to optimize their healing. This diet improves outcomes and prevents wound complications.

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Post Bariatric Plastic Surgery.

The post-bariatric body contouring surgery program continues to grow with more patients enrolling in post-bariatric body contouring procedures.Patients present to our office and are very excited about having their body contouring procedures.

We encourage all patients who desire to have post-bariatric body contouring procedures to bring their insurance cards with them during their consultations. It is a great time to utilize health insurance plans to undergo lap band procedures. Typically after patients undergo their lap band operation they return for their post-bariatric body contouring surgery within 9 months to one year.

Patients are very happy after having their panniculectomy and abdominoplasty surgeries and greatly look forward to having their mastopexy, breast reduction, brachioplasty, or medial thigh lift.

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Body Contouring. Abdominoplasty & Brachioplasty

Patients who have undergone weight loss of greater than 100 lbs. either through diet alone or with the assistance of weight loss surgery need to have their body contouring surgeries performed by a well trained team of physicians.

Post-bariatric patients have significant changes in their body musculature and body physiology, in addition to the excess skin which they are unable to remove with additional diet and exercise.

The patient in the before and after photos above lost greater than 100 lbs. of weight through diet and exercise alone. She was unable to remove the excess skin along her arms and abdomen. She underwent bilateral brachioplasty, or "arm tuck" as well as abdominoplasty with reconstruction of her abdominal wall musculature to restore contour.

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Post-Bariatric Terms:Putting Patients First

BMI stands for body mass index which is in units of (kg/m ^2)

BMI (kg/m2) = Weight in kilograms/Height in meters ^2.

People with a BMI below 18.5 are Underweight.
People with a BMI between 18.5-24.9 are Normal.
People with a BMI between 25-29.9 are Overweight.
People with a BMI above 30 are Obese.

Many insurance companies will authorize lap band surgery if patients meet the following indications:

1. An individual has clinical severe obesity, BMI >40, or BMI> 35 with co-morbidities such as heart disease, diabetes, hypertension, sleep apnea, or degenerative arthritis.2. An individual has suffered from morbid obesity for at least five years. 3. An individual has failed non-surgical attempts at weight loss over the years.4. An individual is at a high-risk for obesity-associated morbidity or mortality. 5. An individual is motivated and has an acceptable operative risk.

Once individuals have had their lap band surgery, they are usually candidates for post-bariatric body contouring surgery 9 to 12 months after. I stress to the patients in our program the importance of adequate protein intake prior to their body contouring operations. For the post-bariatric body contouring patients, it is important to eat 1-2 mg of protein for every kilogram of ideal body weight (IBW) provided they have normal kidney function.

When pre-operative labs are drawn before surgery, it is optimal to have serum albumin levels between 3.5-5 g/dl. It is optimal to have serum pre-albumin levels on the high end of normal levels 17-40 mg/dl. Pre-albumin has a half-life of 1.9 days compared to the half-life of albumin which has a half life of 21 days. Therefore pre-albumin levels tend to be more reflective of the more recent nutritional protein intake.

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Surgery After Weight Loss: RoxBariatric

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 Post-bariatic body contouring surgery is becoming very popular as we are seeing patients not only from Southern California, but now patients from the Midwest who travel to Beverly Hills and Newport Beach to have their post-bariatric surgery performed. More patients are coming to the RoxBariatric Center to meet our team of plastic & reconstructive surgeons and then be introduced to a bariatric surgeon who will perform either a lapband procedure or gastric bypass procedure.

Occasionally, in patients who undergo bariatric surgery or simply loose weight through a bariatric diet, they develop excess of overlying abdominal skin termed a “pannus”.

Patients are coming to the RoxBariatric Plastic Surgery Program from out of state to have their panniculectomy or body contouring surgery performed by our team of plastic & reconstructive surgeons.

Insurance companies will pay for patients to have a panniculectomy performed or removal of this overhanging skin as long as certain criteria are met that deem the procedure medically necessary. These criteria include:

1. Panniculus hangs below the level of the pubis; and
2. Patients have chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs for a period of over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months.
Frequently patients with subcostal scars present for these operations. Subcostal scars are normally right sided scars used to remove the gallbladder. We have seen many patients who have been turned away for abdominoplasty or panniculectomy operations due to the presence of these scars.

These operations can be performed, but need to be performed carefully by plastic & reconstructive surgeons who have demonstrated experience in these operations to ensure proper wound healing. When addressing panniculectomy or abdominoplasty in these patients it is important to respect the remaining blood supply to ensure rapid healing and prevent infection. Adequate nutrition is paramount for proper wound healing.

Brian P. Dickinson, M.D.

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