A critical review of the impact of reconstructive surgery following massive weight loss on patient QoL & a pilot study plan. Jo Gilmartin, Mark Soldin & Prof Andrew Long

Global Obesity Epidemic A major health problem& a growing number of morbidly obese patients are seeking surgical solutions-bariatric surgery Experience ‘prejudice’ & ‘social exclusion’ MWL often leads to excess of lax, overstretched skin causing physical dysfunction/ Psychosocial –QoL problems

Risk of Co-morbidities For example, health consequences such as: Stress on joints, Fatigue, Insomnia Diabetes, Hypertension High blood cholesterol Strokes, DVT’s Heart attacks & kidney failure Anxiety & depression, Powerlessness

Fat Politics Media ideal of thinness, denigrates fatness by linking it to negative characteristics such as ugliness, laziness, failure & anti-social. Marginalised by society Prominence of surveillance-power inequalities Government public health campaigns- lifestyle choices (Tischner & Malson 2008)

Background Patients seeking body contouring after MWL constitutes a rapidly growing patient population in plastic surgery practice (Song et al 2006). However, QOL outcomes following body contouring appears to remain largely unexplored territory.

Literature Review Yielded 12 papers that met the inclusion criteria 7 studies reported that reconstructive surgery following MWL correlated with QoL in several areas (Migliori et al 2006, Song et al. 2006, Pecori et al. 2007, Cintra et al. 2008, Mitchell et al. 2008, Lazer et al and van der Beek et al. 2010)

Results 7 of the studies utilised a retrospective approach. For example, Au et al.(2008) undertook a retrospective random chart review on patients who underwent body contouring from Other studies used a more scientific approach Van der Beek et al. (2010) used OPSQ & Mitchell et al (2008) employed an appearance questionnaire. A few studies used a prospective approach

3 Themes emerged 1. Improved QoL improved physical functioning, improved mental well-being, improved self-efficacy towards eating, improved social acceptance, fewer problems of intimacy and sexuality (van der Beek et al. (2010). Lower scores in body uneasiness (Pecori et al. (2007) positive thinking, body image satisfaction, sexual life resumption or improvement (Migliori et al. (2006)

Improved QoL (Cont’d) Cintra et al. (2008) reported that 87.5% had a positive self-esteem & a very good self image, 68.5 % declared freedom from dependence or disability & a better sex life. Lazar et al. ( 2009) found that 84.6% had improved QoL- better sexual relations (74%), aesthetics (79.5%), psychological status (86.5%) & current life (100%).

Improved QoL (Cont’d) Song et al. (2006) found that body contouring improved QoL significantly, with a mean 55% overall improvement in QoL measurements (n=13), p.<0.01). Mitchell et al. (2008) found some congruency between perceptions of attractiveness & improved QoL.

2. Dissatisfaction from Body Contouring For example, Occurrence of dogs ears in the scar. Results did not match expectations based on Internet examples (van der Beek et al (2010) Dissatisfaction with skin breakdown, most commonly reported being sores, Rashes and skin breakdown in the waist/abdomen area (25%), Chest/Breasts (19%), Thighs (16%), Rear/buttocks area (7%) (Mitchell et al. (2008)

Body Contouring

3. Complications The majority appeared to be related to:- Wound dehiscence – ‘wound distruption’ Tissue necrosis Wound infection Serious Fluid collection Seroma Hematoma/DVT/PE Anemia because of blood loss (Mustoe 2005; Au et al 2008; Cintra et al & de Kerviler et al. 2009)

Implications for health professionals 1. Development of NSF & an ‘ideal’ care pathway to empower this client group. 2. Educate patients about deciphering appropriate sources of information to make a properly informed decision about going ahead. 3. Regulation of cosmetic surgery is concerned with enhancing standards of clinical excellence but excluding ‘professional awareness of cultural & social pressures on women patients’ ( Latham 2008, p.438).

Implications for health professionals cont’d 1. Emphasise patient choice, & promote a stronger patient voice to create autonomy enhancing conditions. 2. The medical power relations appear to be asymmetrical- scientific knowledge & medicalization. 3. Transactional notions of power exploited-problematic 4. Empower potential consumers to access counselling or support networks.

Mapping- Hierarchy of Evidence

Review Limitations 1. Lack of Systematic Reviews & RCT’S. 2. Small Sample size. 3. Single centre database used in all of the studies. 4. Methodology is poorly articulated in some studies (e.g. Mustoe 2005). 5. Many of the studies did not appear to incorporate validated instruments.

Review Limitations Some studies were preoccupied with describing surgical procedures Others only used a case note review Some studies only included women in the sample The majority used a retrospective approach There is a huge scarcity of high-level evidence in regard to QoL Outcomes

Pilot Study Aim: 1. To identify tools & procedures to inform a large scale multicentre study. 2. To identify QoL outcomes from body contouring following massive weight loss. 3. Intent To gain preliminary data for national competitive grant applications to be submitted in the 2011/2012 rounds.

Pilot Study- Approach Mixed Methods 1. Questionnaire- Obesity Psychosocial State Questionnaire 2. Scales 3. Physical health, mental well-being, external contentment, self-esteem, social judgements, self-efficacy towards eating habits, intimacy & sexuality, social network

Method’s Cont’d 2 Semi- structured interviews to explore the participant's experience before and after surgery, focusing on general well-being, body image/identity emotional well-being, levels of function and activity. 3. Demographics & weight characteristics - Medical Records 4. Sample: 20 –25 patients 5. Study Site: Plastic Surgery Dept, St George’s Hospital, London

Pilot Study – Phase 1 Preparation & submission of Pump Priming BID –Successful Outcome. Preparation & submission of Ethical application for approval –was gained from South West London REC 4. Preparation & submission of R&D application for approval –was gained from St George’s Hospital, London.-Dec 2010

Pilot Study- Phase 2 We are setting out to: 1. Identify & recruit patients for the pilot work- Invitation letters sent out 2. Undertake the field work- data collection 3. Undertake a rigorous data analysis 4. Disseminate the results 5. Prepare a grant application for a large scale study

Large Scale Study We are setting out to: Develop a large scale Multicentred study in the UK. Establish a user group to inform the research & ensure it addresses issues of importance to users. Design a rigorous methodology. Establish a dynamic research team. Prepare a robust grant application.

References Cintra W, Modolin, MLA, Gemperli R, Gobbi CIC, Faintuch J, Ferreira MC (2008) Quality of Life after abdominoplasty in women after bariatric surgery. Obesity Surgery. 18: Lazar CC, Clerc I, Deneuve S, Auquit-Auckbur I, Milliez PY (2009) Abdominoplasty after major weight loss: improvement of quality of life and psychological status. Obesity Surgery 19: Migliori F, Rosati C, D’Alessandro G, Giacomo G, & Cervetti S Body Contouring after Bilopancreatic Diversion. Obesity Surgery, 16, Mitchell JE, Crosby RD, Ertlet TW, Marino JM, Sarwer DB, Thompson JK,Lancaster KL, Simonich H, Howell LM (2008) The desire for body contouring surgery after bariatric surgery. Obesity Surgery 18: Mustoe TA (2006) Abdominoplasty:a comparison of outpatient and inpatient procedures shows that it is a safe and effective procedure for outpatients in an office-based surgery clinic. Journal of Plastic and Reconstructive Surgery Tisschner I & Malson H. (2008) Exploring the politices of women’s in/visible ‘Large’, Bodies. Feminism & P sychology, 17 (4)

References Pecori L, GiacomoG, Cervetti S, Marinari G M, Migliori F, Adami G F (2007) Attitudes of morbidly obese patients to weight loss and body image following bariatric surgery and body contouring. Obesity Surgery 17, Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH (2006) Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring) 14: Van de Beek ESJ, te Riele W, Specken TF, Boerma D, van Ramshorst B (2010) The impact of reconstructive procedures following bariatric surgery on patient well-being and quality of life. Obesity Surgery 20: