Lower Body Lift After Massive Weight Loss--Is Outpatient Beltlift Surgery Safe?

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Two thirds of Americans over the age of 20 are overweight; 15 million are morbidly obese (BMI over 40). The number of patients undergoing gastric bypass surgery has risen by over 600% in the past decade: over 220,000 operations were performed in 2009.  The number of patients undergoing body contouring plastic surgery has risen by nearly 400% in the past thirteen years:  over 310,000 tummy tucks, upper arm, breast, buttock, thigh, and lower body lifts were performed in 2010.  56% of these procedures were done in an office surgical center; the other half were evenly divided between ambulatory surgical facility and hospital.* 
*American Society for Bariatric Surgery; American Society for Aesthetic Plastic Surgery statistics

Perhaps not surprisingly, however, most lower body lifts or beltlift operations were performed at the hospital, often with a two-doctor team of plastic surgeons, a 7-9 hour-long operation, overnight stay for 1-3 days, and a total cost of $25,000-$35,000.

There is a better, safer, and less costly alternative—outpatient beltlift surgery in our AAAASF-accredited on-site surgical facility.  But this is true only if the surgeon, his operating team, and the office surgical facility have the necessary experience and capability to safely perform massive skin-removal and tightening operations on an outpatient basis.

Surgical expertise and experience is only a part of the overall picture; what really allows a lower body lift to be done safely as an outpatient is specialized anesthetic management, as well as numerous other essential details.

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 elasticity and collagen content in skin that once contained another whole human in weight.  In fact, patients often 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. Add the cost of multiple plastic surgeries to remove and tighten all that skin, and suddenly outpatient cost savings become a huge factor.

Most board-certified plastic surgeons perform breast lifts and tummy tucks, some perform thigh lifts and upper arm lifts, but ASAPS statistics show that only a few have extensive experience with buttock or full lower body lifts.  Prospective patients should always check that their 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).  Those surgeons who operate in their own office surgical facility should have their operating rooms approved by AAAASF (American Academy for Accreditation of Ambulatory Surgical Facilities) or JCAHO (Joint Commission on Accreditation of Healthcare Organizations).

As massive weight-loss patients reach their body weight goals, one of the greatest areas of concern is the abdomen, where the “apron” or pannus of loose skin folds over the pubic area.  However, often these folds of stretched skin extend 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 and fat that we call a “circumferential belt-lift plus abdominoplasty.”  Other surgeons have described this operation as a “torsoplasty” or “lower body lift,” and have even subclassified them into Type I and II body lifts, but they all describe operations which are lengthy, difficult, and expensive. 

Beltlift (lower body lift) requires a surgical team experienced in total body prepping (the surgical iodine skin scrub 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 incisions and sutures, and the technical surgical and anesthesia details to do this safely, rapidly, and with minimal blood loss.  A review of the surgical literature reveals that most surgeons who perform lower body lifts require inpatient hospitalization, frequently utilize the assistance of a second plastic surgeon, and take 6-10 hours to do the operation.

Longer operations with traditional hospital anesthesia often result in prolonged time in the recovery room, as well as a higher likelihood of postoperative nausea and vomiting from the inhalation anesthetics, nitrous oxide, and intravenous painkiller (narcotic) drugs.  These medications, while providing safe and effective anesthesia, can dilate the gut and middle ear, slow peristalsis in the intestinal tract, and accumulate in fatty tissues (including the brain), causing dizziness, bloating, nausea, vomiting, and that nasty smell as your body exhales the anesthetic gases stored in those tissues.  A simple anti-nausea shot works for some—but for others it’s instant overnight stay.  The cost for just this single hospital operation and overnight care can be 25 to 30 thousand dollars or more.  Add a second or third day and the cost goes up again. Post-operative nausea and vomiting (PONV) occurs in as many as 7-28% of inhalation anesthetic cases.

Hospital or surgicenter inhalation anesthesia is safe, but more importantly for centers with large surgical volumes, it is inexpensive.  Cost, particularly for large hospitals or networks, is a huge factor.  ‘Standard’ anesthetics purchased in bulk are inexpensive, whereas intravenous anesthetics are not only much more costly, but harder to obtain because of supplier/manufacturer shortages.  Unfortunately, what is most cost-effective for the hospital is not always what is best for the patient!

Many AAAASF-accredited plastic surgery in-office surgical facilities offer full general anesthesia capability for their cosmetic surgical patients, and Minneapolis Plastic Surgery’s AAAASF-accredited in-office surgical facility offers complete anesthesia care with one major difference from the hospital—we utilize total intravenous general anesthesia, not just for induction, but for the entire operation. No inhalation anesthetic gases are used, and the same goes for nitrous oxide—these agents just cause too much nausea.  Innovative things are also done with pain and inflammation management, patients are pretreated to avoid nausea, and injection of long-acting local anesthetics is done in areas of muscle spasm or incisional discomfort—in short, all sorts of “extra” steps are employed to reduce or eliminate the potential causes for unplanned overnight hospital admission: pain, nausea and vomiting, or slowness in waking from anesthesia.  This anesthetic regimen is somewhat more costly, but the extra dollars spent on anesthesia results in substantial overall savings since our patients can comfortably go home the same day as surgery, even after a 6 or 7 hour circumferential beltlift.

With this type of high-tech anesthesia, nausea occurs in just under 3% of patients (much lower than hospital statistics), and that includes long operations on all parts of the body.  

In 263 outpatient beltlift operations (from 1997-2011) at Minneapolis Plastic Surgery, Ltd., I am happy to report no major complications, and I believe that this procedure being done as an outpatient actually reduces risks, since our patients are 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 them back to normal faster than the hospital patient.  Outpatient operations also eliminate exposure to sick hospital patients, and nasty bacteria. Our average operating time with one surgeon (and RN first assistant) is 5.7 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 9 pounds of skin per patient (now over 20 pounds in several patients, and over 31 pounds in one patient), and liposuctioned an additional 2 pounds in some.  7 of 263 patients had postoperative nausea (2.7%), and there were few minor complications, all of which resolved with conservative care.  Our beltlift patients are thrilled with their results, particularly considering the savings of thousands compared to identical operations performed as hospital cases.

 

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Minneapolis Plastic Surgeon