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More than one-third of all adults in the United States are obese, with the CDC projecting this rate will only increase over the next two decades.1 This growing epidemic weighs heavily on our health system and poses a serious health risk to future generations. Bariatric surgery has come to the forefront as a highly effective method of combating morbid obesity and its often-associated medical co-morbidities such as diabetes mellitus, hypertension, gastroesophageal reflux disease, obstructive sleep apnea, and hyperlipidemia.2 The popularity of massive weight loss surgery is evident by the rise in bariatric surgery (Table 1) and body contouring.3 The growing trend is unprecedented, as recent advancements in the fields of minimally invasive and plastic surgery have made these options more attractive with improving safety profiles and decreasing complication rates.2
While patients are getting healthier following the significant weight loss that accompanies bariatric surgery, there is a resultant new group of patients presenting with contour changes related to massive weight loss that may be unanticipated, thus adversely affecting postoperative expectations.4,5,9 Patients may not fully comprehend the extent to which their body appearance may change and the impact this may have on their lives. Among the most undesirable changes are the lax excess skin that develops at multiple anatomic sites, spanning the torso and extremities.6,7 In response to these anatomic changes, body contouring surgeries are thus becoming more common, with recent American Society of Plastic Surgeons data showing that procedures specifically associated with massive weight loss are growing at their fastest rate in four years (Table 2). At some level, patients who proceed with these types of elective body contouring surgeries conclude that the benefits that they will derive outweigh the surgical risks. These benefits may include expected improvements in body image, self-esteem, and quality of life.
Studies evaluating the subjective psychological well-being of patients choosing to undergo massive weight loss surgery are well-established in the literature.9,10,14 However, prospective studies that evaluate patients’ subjective improvements as they undergo bariatric surgery and subsequent body contouring using well-validated, self-reported inventories are lacking. With an ever-growing patient population choosing body contouring surgery after massive weight loss, it is increasingly important to understand and better characterize these subjective changes in order to optimize preoperative informed consent and prepare patients to anticipate postoperative outcomes.11,12,13 Thus, we sought to examine effects of bariatric surgery and subsequent body contouring surgery on patients’ body image and quality of life, as well as the durability of those effects following body contouring, using two validated survey instruments. We hypothesized that body image and quality of life would improve with bariatric surgery and improve further following body contouring.
A prospective, two year experience followed patients who underwent bariatric surgery and body contouring. Bariatric patients were given questionnaires preoperatively and at 6, 12, and 24 months postoperatively while body contouring patients were administered these surveys preoperatively as well as 6 and 12 months postoperatively. We employed two validated survey instruments: the Multidimensional Body-Self Relations Questionnaire (MBSRQ) and the RAND Corporation’s Short Form 36 (SF-36).
The MBSRQ is a 34-item inventory of body image divided into sub-scores that include Appearance Evaluation (AE), Appearance Orientation (AO), Body Area Satisfaction Scale (BASS), Overweight Preoccupation (OP), and Self-classified Weight (SW). High scores for AE and BASS indicated satisfaction with one’s appearance. Higher scorers in AO placed more importance on their appearance. High scores for OP reflected greater anxiety and attention to their weight. A high SW reflected greater perception and self-labeling as overweight.14 To assess quality of life, we employed the SF-36 with higher scores demonstrating an improved quality of life.
Repeated measures analyses of variance (ANOVA) F-tests were used to evaluate mean SF-36 score, AO, AE, BASS, OP, and SW over time. All analyses were completed with Statistical Analysis Software version 9.4 (Cary, NC). A p-value < 0.05 was considered statistically significant.
Data was represented with box plots, with each box plot displaying the inner two quartiles of survey responses, the band within each box plot representing the median, and the connecting lines representing the mean for each metric.
A total of 175 patients were surveyed prior to bariatric surgery, with 16 patients surveyed at their 6 month follow up, 19 patients at 12 months, and 4 patients at 24 months. In the MBSRQ data, mean AE scores measured 2.15 preoperatively, improving to 2.55, 2.77, and 2.82 at 6, 12, and 24 months, respectively (p = 0.0033) (Figure 1). Mean BASS scores demonstrated significant improvements, from 2.42 to 2.96, 2.65, and 2.75 (p = 0.0079) (Figure 2). Furthermore, mean AO scores increased from 3.40 preoperatively to 3.47, 3.87, and 4.04 postoperatively (p = 0.044) (Figure 3). The decrease in mean OP scores from 3.27 to 3.09, 3.25, and 3.00, did not achieve statistical significance (p = 0.549) (Figure 4). However, mean SW scores decreased significantly, from 4.65 preoperatively to 4.00, 3.89, and 3.63 postoperatively (p < 0.0001) (Figure 5).
The mean SF-36 score for patients awaiting bariatric surgery was 54.1%. By comparison, postoperative scores at 6, 12, and 24 months were significantly higher, measuring 67.6%, 74.0%, and 76.7% (p < 0.0001) (Figure 6).
The body contouring group consists of 41 patients: 32 panniculectomies (78%), three belt lipectomies (7%), two lower body lifts (5%), two upper body lifts (5%), and two breast reductions (5%). Thirty-one patients were surveyed at 6 months and 27 patients at 12 months. Questionnaires were given preoperatively and at both specified intervals postoperatively. In the MBSRQ data, mean AE scores were 2.33 preoperatively, improving to 2.89 and 3.01 at 6 and 12 months, respectively (p = 0.0001) (Figure 7). Mean BASS scores demonstrated significant improvements, from 2.71 preoperatively to 3.07 and 2.91 (p = 0.0005) (Figure 8). Mean AO scores declined significantly from 3.98 pre-body contouring to 3.91 and 3.77 postoperatively (p = 0.0055) (Figure 9). The decrease in mean OP scores from 3.35 to 3.25 and 3.24 did not achieve statistical significance (p = 0.261) (Figure 10). However, mean SW scores did decrease significantly from 3.70 pre- to 3.52 and 3.37 postoperatively (p = 0.0286) (Figure 11).
The mean SF-36 score for patients before body contouring was 71.3%. Postoperative scores at 6 and 12 months were not statistically different at 72.9% and 64.5% respectively (p = 0.32) (Figure 12).
The effectiveness of bariatric surgery in treating obesity is well-established in the literature.15 Bariatric surgery results in significant weight loss and helps prevent, improve, or resolve a majority of obesity-related diseases and conditions.15 However, the benefits of bariatric surgery and body contouring on patients’ self-image and quality of life have, to date, been unclear. Our institutional data demonstrate that bariatric surgery and body contouring after significant weight loss both enhance patient body image and quality of life.
For the post-bariatric surgery cohort, the MBSRQ data revealed improvements among several components of the patient’s body image evaluation. Appearance Evaluation as well as Body Area Satisfaction Scale scores revealed significant improvements at all time-points postoperatively. Both of these scores reflect patients’ improving satisfaction with their appearance following bariatric surgery. The improvement is also substantiated with decreased Self-classified Weight scores at all postoperative time points, reflecting a decrease in patients’ perceptions of labeling themselves as overweight. Finally, Quality of Life based on SF-36 scores also showed significant and durable improvements at all time-points post-bariatric surgery.
Furthermore, the body contouring cohort revealed similar findings of improved body image. Mean Appearance Evaluation scores demonstrated significant improvements at 6 and 12 months compared to preoperatively. Mean Body Area Satisfaction Scale scores also showed statistically significant improvements. The postoperative declines in Overweight Preoccupation and Self-classified Weight did not reach statistical significance. With continued enrollment and improving study power, we anticipate detectable improvements in these metrics.
As most changes observed in the body contouring group mirrored those seen in the bariatric group, one unexpected observation is the paradoxical increase in Appearance Orientation scores following bariatric surgery, with scores decreasing following body contouring. AO scores reflect the importance patients place on their appearances, with higher scores signifying greater preoccupation with their personal appearances. The initial increase in AO scores following bariatric surgery can be explained by patients’ increasing preoccupations with the physical changes that follow their massive weight loss. That is, patients may perceive newfound attractiveness after losing substantial amounts of weight. In addition, patients may begin to focus on the excess skin and panniculus that often develop, further increasing patients’ preoccupations with their appearances, which again manifests in increased AO scores. Subsequent body contouring mitigates or drastically reduces the undesirable excess skin areas, which serves to reduce the patients’ heightened preoccupations over their appearances, with AO scores consequently decreasing. Our finding highlights the importance of body contouring in the progression of massive weight loss surgery and its value in optimizing post-bariatric surgical results.
The follow-up encounters after bariatric surgery show mean quality of life scores between 74% and 76% at 12 and 24 months post-bariatric surgery, while pre-body contouring scores were lower at 71%. We can account for this decrease in quality of life scores by the fact that not all massive weight loss patients choose to undergo body contouring. Patients with higher self-reported quality of life scores most likely are satisfied with their initial progress. By contrast, patients who report lower quality of life scores choose to undergo body contouring in hopes of achieving further satisfaction from their weight loss surgery.
Significant improvements in several MBSRQ categories are noted at six and twelve months after body contouring, suggesting that these improvements are durable over time. By contrast, quality of life scores demonstrated no significant improvements, which we may attribute to increases in complications seen in post-bariatric body contouring surgeries17,18 or as a reflection of our sample size. Gaining an understanding of body satisfaction over time as patients proceed from bariatric through body contouring surgery will assist clinicians in providing guidance, preoperative counseling, and informed consent. The improved discussion with patients may better align their preoperative expectations regarding changes in body image and quality of life with their postoperative outcomes.
The small number of patients seen in follow-up is an acknowledged weakness of this study. Despite the limited patient follow-up, we nonetheless find clear statistical significance in many measured metrics consistent with our initial hypothesis. Our data support bariatric surgery having a positive impact on patients’ views of their body image after massive weight loss surgeries. Improvements in body image perceptions and quality of life are durable as evidenced by their stability up to two years postoperatively. In addition, massive weight loss patients who undergo subsequent body contouring surgery also show improvements in body image. Our current data suggest that bariatric surgeries followed by body contouring procedures help patients achieve optimal functional and aesthetic results as compared to bariatric surgeries alone.
In our present body contouring cohort, 90% have undergone panniculetomy procedures (i.e., panniculectomies, belt lipectomies, and lower body lifts), with the remaining procedures divided evenly between upper body lifts and breast reductions. Future studies will focus on evaluating differences in patient quality of life and body image associated with specific contouring procedures, as well as the effect of surgical complications on quality of life.
Finally, as the U.S. healthcare system increasingly demands demonstrated value associated with surgical interventions, we provide data for patients and healthcare providers to better advocate for increased insurance coverage for body contouring procedures following massive weight loss surgery. Our study demonstrates that massive weight loss surgery achieves its maximum value following body contouring, based on further incremental improvements in body image. Using two validated survey instruments, we have provided early evidence for insurers to recognize the importance that body contouring has following massive weight loss.
Through use of two validated survey instruments, we show that patients undergoing bariatric surgery demonstrate significant and durable body image and quality of life improvements. Our data also demonstrate that post-bariatric body contouring also improves patients’ body image, based on significant increases in the MBSRQ Appearance Evaluation and Body Area Satisfaction scores. The data may prove beneficial to patients in making informed decisions about whether to proceed with body contouring surgery following massive weight loss. Our study’s results give healthcare providers supportive evidence for the value of body contouring after massive weight loss. We hope that this demonstration of value may afford an ever-growing patient population stronger advocacy in obtaining insurance coverage.
sources of funding: Chin-Shang Li and Yu Liu are currently supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH) grant (#UL1 TR000002).
Conflicts of interest: For the remaining authors none were declared.
Presented at the 2015 Annual Meeting of the American Society of Plastic Surgeons, Boston, MA on October 17, 2015.
Presented at the 65th Annual Meeting of the California Society of Plastic Surgeons, Monterey, CA on May 24, 2015.
Presented at the 60th Annual Meeting of the Plastic Surgery Research Council, Seattle WA on May 15th, 2015.
This is a California Society of Plastic Surgeons paper. This is to be reviewed by the CSPS Annals Review Committee to be published in the special CSPS edition set for May 2016.