Jonas Ockell – On massive weight loss and body contour – Breast measurements and excess skin before and after bariatric surgery and in the normal population

Link directly to the doctoral thesis in GUPEA.

Abstract

Background/Aims
Bariatric surgery is an effective treatment for severe obesity. However, massive weight loss is associated with adverse effects, such as excess skin. The overall aim of this thesis was to investigate the effect of obesity and massive weight loss on excess skin on arms, thighs, breasts, and abdomen, compared to a normal population.

Materials and methods
The studies were conducted at Sahlgrenska University Hospital, Carlanderska Hospital, and Art Clinic, Gothenburg, Sweden. In Paper I, a questionnaire designed to evaluate excess skin, mainly in post-bariatric patients (the SESQ), was sent to 1408 individuals of a normal population to produce reference values, 530 responded. Papers II-III were prospectively designed to study excess skin on the extremities and breasts, before and after bariatric surgery, as well as breast measurements in women with obesity (n =200). A secondary aim was to find prediction models for post-operative discomfort from excess skin in arms, and thighs, and change in breast measurements after weight loss. In Paper IV, a modified technique for abdominoplasty on post-bariatric patients with residual obesity was evaluated regarding complications and patient satisfaction, to evaluate the safety and efficiency (n= 130).

Results
Paper I revealed that most responders do not report excess skin (78%). As with post-bariatric patients, the most common locations were the abdomen, arms, breasts/chest which also caused the most discomfort. In Paper II, most physical measurements on the extremities decreased after bariatric surgery. The patients, especially the women, however, perceived that the amount increased and resulted in more discomfort. The patients that likely will suffer the most from the excess skin can be predicted before bariatric surgery, by measuring the ptosis of the upper arms and thighs. In Paper III, the study resulted in reference values for breast measurements for women with obesity, thus adding to the previous standard of normality.

Furthermore, a model for predicting the effect of weight loss on these measurements was  described. In Paper IV, the results indicate that a modified abdominoplasty may be a safe and effective compromise for post-bariatric patients with residual obesity.

In summary
Most of the normal population does not report excess skin, adding to the validity of the SESQ. Most physical measurements of the arms and legs decrease after bariatric surgery, but many patients perceive that the amount and discomfort increase. It is possible to predict which patients will suffer most from excess skin on the extremities after bariatric surgery. Breast measurements are related to BMI, and it is possible to predict the changes in these measurements with a change in BMI. Finally, a modified abdominoplasty may be a feasible compromise for a safe and yet effective treatment for excess abdominal skin for post-bariatric patients with residual obesity.

CONCLUSION from page 71 in thesis

• As measured by the SESQ, most of the normal population does not report excess skin, strengthening the validity of the PROM.
• Most post-bariatric patients report increasing amounts of excess skin on the upper arms and thighs, although most measurements decrease.
• Women report increasing discomfort from excess skin on the extremities after weight loss.
• It is possible to predict which patients will be most discomforted by excess skin on the upper arms and thighs.
• There is a relationship between breast measurements with increasing BMI.
• The standard of normality for breast measurements is now completed with reference values for women with overweight and obesity.
• It is possible to predict the change in breast measurements with weight loss.
• Women experience significantly more excess skin and subsequent  discomfort from excess skin on the breasts after bariatric surgery as compared to before.
• With modifications in surgical technique, a standardized peri-operative protocol, and a follow-up routine, abdominoplasty may be a safe procedure for post-operative patients with residual obesity.
• Post-bariatric patients with BMI 30-40 may benefit as much, or more, from modified abdominoplasty regarding QoL and continued weight loss compared to patients with BMI < 30 undergoing standard abdominoplasty.