Special Surgery - Unique Patients

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Understanding the characteristics of massive-weight-loss patients is as important as knowing how to operate on them

Surgery following massive-weight-loss (MWL), or bariatric, surgery is a unique field within plastic surgery in certain ways. It has aspects of both reconstructive and aesthetic surgery. As a plastic surgeon whose practice has many MWL patients, I have come to realize that these patients have unique characteristics:

• They all have a history of clinically severe obesity (the new term for massive obesity);

• they have undergone bariatric surgery with varying results, typically within the previous 1 to 4 years;

• they are strongly determined to get rid of their loose skin; and

• they are mostly women.

Aesthetic surgery on these patients has been on the rise as gastric-bypass procedures have gained popularity in the last 10 years. Bariatric surgery and subsequent aesthetic surgery for the MWL patient are challenging, and much has been written about these procedures. But the literature on understanding and dealing with the MWL patient is sparse.

For an aesthetic surgeon, identifying candidates for plastic surgery and knowing how to take care of the average patient can be challenging. It has been said that aesthetic surgery is psychiatry with a knife. MWL patients present a new challenge. These patients do not fit into a specific “mold,” but they have some common behaviors and medical issues.

For some, the decision to undergo bariatric surgery is part of a “new me” plan. They undergo a bariatric procedure, lose the weight, and find themselves ready to eat right, exercise, and in general alter the unhealthy lifestyles that had brought them to clinically severe obesity.

Changes occur in the process of weight loss with respect to family dynamics, romantic relationships, social interactions, work habits, self-esteem, and other life issues that may be unique to each individual patient. The more that plastic surgeons are tuned in to those changes, the better we are able to serve these patients. Ideally, plastic surgery on MWL patients provides enormously positive results for their self-image, self-esteem, attitude, and—ultimately—their health.

Preparing for Surgery

“The secret of the care of the patient is in caring for the patient”.

-Sir Francis Peabody

A user-friendly office. The first step in making MWL patients feel comfortable is to make them feel welcome and understood. It starts in the reception area. The chairs or sofas must be comfortable and able to accommodate large individuals. A warm reception from the office staff goes a long way toward making an already nervous prospective patient feel welcome.

The examination rooms should be equipped with exam tables and chairs for larger patients. Special large-sized gowns should be available, if needed. The office staff should understand the terms necessary to communicate effectively with MWL patients, such as “roux-en-Y,” “lap band,” and “dumping syndrome.”

The office manager or scheduler should explain the finances very clearly to patients, especially when the surgery is to be paid for out of pocket. The fees discussed should include those for the surgeon, hospital, and anesthesiologist. Pa­tients should also be made aware of fees associated with complications and touch-up procedures.